Failure to Conduct Timely Physician Visits
Penalty
Summary
The facility failed to ensure that physician visits were conducted at least every 60 days after the first 90 days of admission for one resident. Specifically, Resident R86 was admitted to the facility on February 7, 2024, and had diagnoses including stroke, hypertension, and dysphagia. However, there was no documented evidence of a physician or physician delegate visit for 232 days between February 7, 2024, and September 25, 2024, which is a violation of the required frequency of physician visits. Additionally, the facility did not ensure that a physician completed the initial visit for another resident, Resident R201. This resident was admitted on December 17, 2024, with diagnoses of anxiety, depression, and bipolar disorder. The initial visit was conducted by a Certified Registered Nurse Practitioner, Employee E14, instead of a physician, as required. The Nursing Home Administrator confirmed these deficiencies during an interview on January 16, 2025.
Plan Of Correction
Facility cannot retroactively correct and will ensure moving forward that physician visits are conducted at least every 30 days for the first 90 days and then at least every 60 days thereafter. Residents #86 and #201 were immediately evaluated by a physician to ensure facility alleges compliance with regulatory requirement of F712 (Physician Visits - Frequency/Timelines/Alt NPP). To identify other residents that have the potential to be affected, the DON/designee will audit current resident admission assessments to ensure initial admission assessment is completed by a physician within required timeframe and all subsequent physician visits are completed per requirement. Negative findings will be addressed. To prevent this from recurring, the NHA/designee educated Medical Director on initial admission assessment to be completed by a physician within required timeframe and all subsequent physician visits to be completed per requirement. To monitor and maintain ongoing compliance, the DON/designee will audit physician visit assessments weekly x4 then monthly x2. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.