Deficiency in Physician Visits and Documentation
Penalty
Summary
The facility failed to ensure that the physician responsible for supervising the care of residents conducted face-to-face visits and wrote progress notes at least every thirty days for the first ninety days of admission. This deficiency was observed in four residents who were reviewed for physician visits. The facility's policy required that physicians make rounds every day and document in the electronic medical record (EMR), with an expectation for a history and physical (H&P) within 24 hours of admission and monthly physician visit progress notes. However, the records for these residents showed inconsistencies and gaps in documentation by the attending physician. Resident #51, admitted with multiple diagnoses including hypertension and schizophrenia, had no progress notes from the attending physician from May to December 2024. The nurse practitioner (NP) documented visits, but there was no evidence of alternating monthly visits between the physician and NP. Similarly, Resident #52, with diagnoses including hypertension and anxiety disorder, had only a few documented visits by the attending physician and physician assistant (PA)/NP, with missing progress notes for several months. Resident #119, who had a tracheostomy and was cognitively intact, also lacked progress notes from the attending physician for several months. The NP documented visits sporadically, but there was no consistent alternation of visits. Resident #122, with type II diabetes mellitus and anxiety disorder, had NP visit progress notes but no documentation from the attending physician for several months. The Director of Nursing (DON) confirmed the expectation for physician visits and documentation, but the surveyor noted the deficiencies in the facility's adherence to these requirements.
Plan Of Correction
F712- Physician Visits What corrective action will be accomplished for those residents affected by the deficient practice? The Director of Nursing and Director of Clinical Services spoke with the Medical Director and advised of policy on Physician Visits. The Medical Records for identified residents could not be retroactively updated to include physician visits. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be affected by this deficient practice. Managers audited clinical records and contacted physicians with any findings. What measures will be put into place or what systemic changes will be made to ensure the deficient practice will not recur? The Policy for Physician Visits was reviewed. The Director of Clinical Services, Director of Nursing and or the Medical Director began education on January 8th, 2025 to the primary physicians on staff of the policy on Physician Visits. Unit Managers will monitor resident records to ensure physicians are making visits at appropriate intervals. How will the corrective action be monitored to ensure the deficient practice will not recur? Audits will be conducted by Nursing Administration on Physicians Visits/Frequency/Timeliness, weekly x4, then monthly x3. The results of the audit will be reviewed at the monthly QAPI Committee chaired by the facility administrator.