Failure to Document Physician and CRNP Progress Notes
Penalty
Summary
The facility failed to ensure that the physician and the Certified Registered Nurse Practitioner (CRNP) wrote, signed, and dated progress notes with each visit for two residents. For one resident, a nursing note indicated that the resident was seen by the physician at the bedside, and new verbal orders were received. However, there was no documented evidence of a progress note from the physician for this visit until a month later when it was faxed to the facility. The Director of Nursing confirmed the absence of the progress note in the resident's clinical record until it was received by fax. For another resident, who was a new admission from the hospital, there was no documented evidence of a progress note for the initial admission visit by the physician. The Director of Nursing confirmed the lack of documentation and mentioned that the physician recalled seeing the resident. Additionally, hospital discharge instructions indicated that the resident was to have sutures removed, but there was no documented evidence that the CRNP completed a progress note regarding the suture removal. The LPN/Infection Control Preventionist confirmed the absence of documentation and noted that the CRNP was behind in updating progress notes.
Plan Of Correction
Preparation and submission of this Plan Of Correction (POC) is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. The facility is not able to obtain previous physician note for Resident #84. At the time of the survey, the facility obtained the note for Resident #84 from the Certified Registered Nurse Practitioner. At the time of the survey, the facility obtained the note for Resident #79 from the physician. To identify other residents with the potential to be affected, the Director of Nursing/designee will audit a 2 week look back of physician and certified Registered Nurse Practitioner visits to ensure notes are present. To prevent a future occurrence, the Director of Nursing/designee provided education to the physician and Certified Registered Nurse Practitioner on writing a note for each resident that they visit. To monitor and maintain ongoing compliance, the Director of Nursing/designee will complete an audit weekly x4 then monthly x2 to verify a note is present for each resident that they visit. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.