Failure to Conduct Required Physician Visits and Document Progress Notes
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 as required. This deficiency was identified for two residents. Resident #95, who was admitted with diagnoses including pneumonia, chronic respiratory failure, and pulmonary fibrosis, did not have any Physician Progress Notes (PPN) documented since admission. Despite being cognitively intact, as indicated by a score of 14 out of 15 on the Brief Interview for Mental Status (BIMS), there were no PPNs found in the resident's hybrid medical records. The Licensed Practical Nurse Unit Manager confirmed the absence of PPNs and noted a change in the primary physician from MD#2 to MD#1, effective 11/15/24. MD#2, who was responsible for the resident's care, last visited the facility in October 2024 but could not explain the lack of documentation. Similarly, Resident #103, admitted with chronic systolic heart failure, type 2 diabetes mellitus, and hypertension, also lacked PPNs since admission. The resident, who was cognitively impaired with a BIMS score of 7 out of 15, had only an initial physician's admission note dated 10/2/24, with no subsequent PPNs documented. The facility's policy requires physicians to see residents within 30 days of admission and at least every 30 days for the first 90 days, then every 60 days thereafter. The Director of Nursing acknowledged the documentation concern but provided no further information.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with end stage renal disease, sexual dysfunction, major depressive disorder, and liver cirrhosis, who was cognitively intact and receiving dialysis, was not seen by a physician within the required initial 30-day period after admission. The first documented physician assessment occurred several months later, even though the resident had been seen by an NP and a PA during that time. Review of records and staff interview confirmed the absence of a timely physician visit, resulting in noncompliance with required physician visit frequency and timeliness.
A resident was not seen by a provider throughout their entire admission, as confirmed by the absence of physician progress notes in the medical record. The resident was cognitively intact, and facility policy stated that residents should receive care from medical practitioners as needed.
The facility did not ensure that the Medical Director conducted required face-to-face visits with several residents, all of whom had complex medical conditions such as dementia, diabetes, and Alzheimer's disease, within the mandated 60-day interval. The Medical Director was unaware of this requirement, resulting in missed visits for these individuals.
The facility did not ensure that required face-to-face physician visits were conducted at least every 60 days for four residents with various medical conditions, as confirmed by record review and DON interview. The most recent visits for these residents were completed several months prior, and no subsequent visits were documented within the regulatory timeframe.
A resident with multiple chronic conditions did not have any in-person examination notes documented by the attending physician since admission. Instead, the Medical Director only co-signed notes from a Physician Assistant or Nurse Practitioner, contrary to facility policy requiring a physician's own progress note during visits. The DON confirmed the absence of required physician documentation.
A resident with severe cognitive impairment and complex medical needs did not have documented physician visits as required. Only an admission visit and a physician order were found in the record, and facility leadership could not provide evidence of additional required visits, despite the physician stating that notes had been sent.
Failure to Provide Timely Initial Physician Visit After Admission
Penalty
Summary
The facility failed to ensure that a resident was seen by a physician within the first 30 days after admission, as required by §483.30(c). The resident was admitted on 06/25/25 with diagnoses including end stage renal disease, sexual dysfunction, major depressive disorder, and liver cirrhosis, and a quarterly MDS documented that the resident was cognitively intact and received dialysis. Review of the medical record showed that the first documented physician assessment did not occur until 12/10/25, well beyond the required initial 30-day timeframe. Although the resident was assessed by a nurse practitioner and a physician assistant prior to that date, there was no documentation of a timely physician visit. In an interview, the MDS nurse confirmed that the resident had not been assessed by a physician within the first 30 days after admission and that the first physician assessment at the facility occurred on 12/10/25. This deficiency affected one of three residents reviewed for physician visits, in a facility with a census of 47 residents.
Plan Of Correction
Physician Visits-Frequency/Timeliness/Alt NPP The PoC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident # 28 has been seen by the facility physician on 3-18-2026. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken A sweep of new admissions to the facility has been completed by 4-1-26 by the ADON and the physician has seen all new admissions within the first 30 days of admission. The sweep included the last 30 days audit of residents that they have been seen by the physician. all have been seen. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. DON/designee has in-serviced nursing management and nurses that they must ensure residents are assessed by a physician within the first 30 days after admission. Inservice completed on 3-31-2026. Medical director was in serviced that he will need to see new admissions within 30 days of admission on 3-18-26 by the DON. How the corrective action will be monitored to ensure the deficient practice will not recur. DON/designee is auditing new admissions for compliance with physician visit within 30 days weekly x 2 months and submitted to the weekly QAPI committee. The audits began 3-31-26. If any concerns are noted, the MD will be alerted to come in to see the resident in a timely. The audits will alert the adon that the time limit is approaching.
Failure to Ensure Required Physician Visits During Admission
Penalty
Summary
A review of the medical record, staff interviews, and facility policy revealed that a resident was not seen by a provider during the entire admission period from 05/07/25 through discharge on 08/21/25. The medical record for this resident, who was cognitively intact according to the five-day Minimum Data Set (MDS) assessment, showed no physician progress notes for the duration of the stay. Facility assessment documentation indicated that residents should expect a standard of care from medical practitioners and other healthcare professionals necessary to provide the required support and care. This deficiency was identified during an investigation under Complaint Number 2572811.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that the Medical Director conducted face-to-face visits with residents at least once every 60 days, as required. Medical record reviews and staff interviews revealed that four residents, each with significant medical diagnoses such as pneumonia meningitis, ulcerative colitis, viral hepatitis, non-traumatic brain dysfunction, dementia, diabetes, cancer, coronary artery disease, Alzheimer's disease, renal insufficiency, and psychotic disorder, had not been seen by the Medical Director within the mandated timeframe. The last documented visit for these residents was on the same date, and subsequent review confirmed that no follow-up visits occurred within 60 days. During an interview, the Administrator acknowledged that the Medical Director was unaware of the requirement to see residents every 60 days.
Failure to Conduct Timely Physician Visits
Penalty
Summary
The facility failed to ensure that required face-to-face physician visits were conducted at least every 60 days for four residents. Record reviews showed that the most recent regulatory visits and exams for these residents were completed in March 2025, with no subsequent visits documented within the required timeframe. The residents affected had various diagnoses, including Alzheimer's disease, diabetes mellitus, emphysema, dementia, major depressive disorder, cerebrovascular disease, hemiplegia, hemiparalysis, seizures, non-traumatic brain dysfunction, heart failure, and hypertension. Cognitive assessments ranged from intact to severely impaired cognition. An interview with the Director of Nursing (DON) confirmed that the facility did not currently have a physician available to conduct in-person regulatory visits, resulting in the lapse of required visits for the identified residents. This deficiency was identified during the investigation of a specific complaint and affected a facility census of 102 residents.
Lack of Physician In-Person Examination Documentation
Penalty
Summary
The facility failed to provide evidence that the attending physician conducted in-person examinations for all residents as required. Specifically, for one resident with multiple complex diagnoses including Type 2 Diabetes Mellitus with neuropathy, asthma, morbid obesity, bipolar disorder, atrial fibrillation, acute respiratory failure, hypertension, and hyperlipidemia, there were no physician progress notes documented in the medical record since admission. The medical record review showed that the Medical Director, who was the attending physician, only co-signed notes written by a Physician Assistant or Nurse Practitioner and did not write any direct physician notes for the resident. The facility's policy requires the physician to review the resident's plan of care during visits and to write and sign a progress note, but this was not followed in this case. The Director of Nursing confirmed the absence of physician notes for the resident.
Failure to Ensure Required Physician Visits for Resident
Penalty
Summary
The facility failed to ensure that physician visits were provided as required for a resident with multiple complex medical diagnoses, including osteonecrosis, gastrostomy, a history of malignant neoplasm, and nicotine dependence. The resident, who had severe cognitive impairment and was dependent on a feeding tube for the majority of nutritional needs, had documentation of an admission physician visit and a subsequent physician order fax, but no other physician visits were found in the medical record. During interviews, the attending physician stated that a visit had been completed and notes sent to the facility, but facility leadership was unable to provide evidence of any required physician visits beyond the initial documentation. This lack of documentation and evidence of ongoing physician visits constituted the deficiency.
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