Failure to Ensure Physician Face-to-Face Visits and Orders
Summary
The facility failed to adhere to its policy and procedure regarding physician services, specifically in ensuring that physicians perform the initial face-to-face visit, sign admitting physician orders, and alternate visits with a non-physician practitioner (NPP). This deficiency was identified for one resident who was admitted with a history of subdural hematoma, end-stage renal disease requiring dialysis, and multiple myeloma. The resident's admission record and subsequent medical documentation, including the history and physical, physician orders, and progress notes, were all signed by an NPP, with no evidence of a physician's face-to-face contact. The Director of Nursing confirmed that the facility's policy required physician visits and documentation to comply with current regulations, which mandate that physicians must perform the initial comprehensive visit and sign admission orders. The review of the Code of Federal Regulations further supported that NPPs are not permitted to perform these initial tasks in skilled nursing facilities. The lack of physician involvement in the resident's care raised concerns about the thoroughness of assessments and the safety and adequacy of care provided.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with cancer, kidney disease, malnutrition, and a seizure disorder did not have documentation of the required initial face-to-face physician visit within the first 30 days after admission. The DON stated the physician should have seen the resident during the first month, but no progress note or other record of the visit was found, despite the facility policy requiring monthly physician visits for the first 90 days.
Physician Did Not Complete Initial Assessments for Three Residents: The facility failed to ensure the MD completed the initial assessment within 30 days of admission for three residents. Each resident had the initial physical assessment completed by the APRN on behalf of the MD, and two residents stated they did not believe they had been seen by a doctor in the facility. The MD said he rounds weekly and only completes initial assessments when admissions occur on certain days; otherwise, the APRN completes them.
Missing physician progress notes for a resident were identified during record review. The MDS nurse and MRD could not locate PPN for the last three months, and the facility’s policy required the attending MD to write, sign, and date PPN at each visit and complete required resident visits on schedule.
Physician Did Not Complete Required Initial Visit Within 72 Hours: A resident admitted with ankylosing spondylitis, dysphagia, and HTN did not receive the required initial physician visit within 72 hours of admission. RN notified the physician of the admission by text, and the physician responded with medication instructions, but the DON confirmed no visit by the attending physician or medical director was documented during the first several days after admission.
Physician Visits Not Provided as Required: The facility failed to ensure required physician face-to-face visits for five residents. The affected residents had significant medical and cognitive conditions, including dementia, schizophrenia, COPD, diabetes, and severe cognitive impairment. Record review and DON interview confirmed gaps in physician visits, with some residents seen only by the NP and not by the physician within the required timeframes.
Missed Required Physician and NP Visits: The facility failed to ensure required face-to-face physician or NP visits occurred every 60 days for three residents. Records showed gaps in routine assessments for residents with dementia, CHF, CAD, HTN, and functional dependence, and the physician acknowledged that some visits slipped by while he tracked them with scheduler software and did not have an NP to assist.
Physician Did Not Complete Required Initial Visit
Penalty
Summary
The facility failed to ensure that a resident's physician completed the initial comprehensive 30-day face-to-face visit for one of three newly admitted residents reviewed. R50's admission MDS indicated diagnoses of cancer, kidney disease, malnutrition, and a seizure disorder, and the census report showed R50 remained an active resident with Medicare A as the primary payer and had been admitted to the facility. Review of the medical record did not find a progress note showing that a physician visit had been completed during the resident's stay. During interview, the DON stated the physician should see the resident within the first 30 days and said she would look for documentation that the physician had seen R50, but records showing a physician visit were not received. The facility's Physician Visits policy stated the attending physician must visit residents in a timely fashion and once every thirty days for the first 90 days.
Physician Did Not Complete Initial Assessments for Three Residents
Penalty
Summary
The facility failed to ensure the physician completed the initial assessment within 30 days of admission for 3 of 3 residents reviewed. Resident #1 was admitted with diagnoses including dependence on renal dialysis, type II diabetes, anemia, acute respiratory failure, major depressive disorder, polyneuropathy, and muscle weakness. His admission MDS documented a BIMS score of 15/15, indicating intact cognition, and the first physical assessment showed he was seen by the APRN on behalf of the medical doctor rather than by the physician. Resident #7 was admitted with diagnoses including shortness of breath, heart failure, atrial fibrillation, essential hypertension, cardiac pacemaker, seizures, and major depressive disorder, and her admission MDS documented a BIMS score of 15/15. Resident #8 was admitted with diagnoses including schizophrenia, muscle weakness, chronic pain, and tachycardia, and her admission MDS documented a BIMS score of 12, indicating moderately impaired cognition. For both residents, the initial physical assessment documented that the APRN saw the resident on behalf of the medical doctor. During interviews, the physician stated he rounds every Thursday and reviews APRN notes before signing off, and confirmed that the APRN completes initial assessments on days when residents are admitted other than Wednesday or Thursday. Both Resident #7 and Resident #8 stated they did not believe they had been seen by a medical doctor in the facility.
Missing Physician Progress Notes for Resident
Penalty
Summary
The facility failed to ensure physician progress notes were completed for Resident 90 for the months of February, March, and April 2026. During record review, the Medical Records Director reviewed Resident 90’s physician progress notes and stated there were no notes for those three months, adding that physicians usually fax the notes. The Minimum Data Set Nurse also reviewed the record and stated she could not find the physician progress notes for the last three months, and stated that physician progress notes should be completed monthly. The facility’s policy on Physician Visits stated the attending physician must visit residents at least once every thirty days for the first ninety days after admission and then at least every sixty days thereafter, and must complete relevant documentation at each visit. The facility’s policy on Physician Progress Notes stated the attending physician must write, sign, and date the physician progress notes upon each visit.
Physician Did Not Complete Required Initial Visit Within 72 Hours
Penalty
Summary
The facility failed to implement its policy titled Physician's Untimely Visit for one sampled resident who was admitted with ankylosing spondylitis, dysphagia, and hypertension. The resident's face sheet showed admission to the facility on 5/08/2026, and the clinical admission record documented arrival by ambulance with a family member. A text message from RN 1 to Physician 1 on the day of admission notified the physician that the resident had been admitted, and the physician replied with instructions to follow the hospital discharge medication list exactly. During interview and record review on 5/12/2026, the DON stated that the resident's physician had not conducted a visit from the admission date through 5/12/2026, which was more than 72 hours after admission. The DON also stated she was unable to provide documentation showing that either the attending physician or the medical director had visited the resident during that period. The facility policy reviewed during the investigation stated that physician visits are to be completed within 72 hours of admission and that the administrator shall notify physicians to comply with facility policy and state and federal regulations.
Physician Visits Not Provided as Required
Penalty
Summary
The facility failed to ensure physician visits were provided as required for five residents reviewed for physician visits. Resident #42, with diagnoses including acute and chronic respiratory failure, type 2 diabetes, peripheral vascular disease, anxiety, and schizoaffective disorder, had moderate cognitive impairment and rejected care one to three days in the seven-day look-back period. The record showed physician visits on 04/24/25, 08/07/25, 09/11/25, 09/25/25, and 03/05/26, and the DON confirmed there were no other visits and that the resident was not seen by the physician as required between 09/25/25 and 03/05/26. Resident #44, with dementia with behavioral disturbance, psychosis, anxiety, type 2 diabetes, and schizophrenia, had moderate cognitive impairment with inattention and disorganized thinking; physician visits were documented on 07/03/25, 07/10/25, 08/21/25, 02/19/26, and 03/19/26, and the DON confirmed there were no other visits and that the resident was not seen as required between 08/21/25 and 02/19/26. Resident #53, admitted with Alzheimer’s disease, dementia, depression, anxiety, and Crohn’s disease, had severe cognitive impairment and was seen by the physician only once, on 09/04/25; the DON confirmed there were no other visits and that the resident had not been seen as required since that date. Resident #5, with multiple sclerosis, COPD, dementia, and chronic kidney disease, had severe cognitive impairment, rejected care four to six days in the review period, and was dependent for most ADLs; the record showed physician visits on 09/11/25 and 01/22/26, and the DON stated there were no other physician visits, only the nurse practitioner. Resident #35, with schizoaffective disorder, dementia, anxiety, hypertension, and COPD, had impaired cognition with moderate depression and fluctuating disorganized thinking; physician visits were documented on 07/10/25 and 11/20/25, and the DON verified the resident had not seen the physician since 11/20/25, only the nurse practitioner.
Missed Required Physician and NP Visits
Penalty
Summary
The facility failed to ensure physician or nurse practitioner face-to-face visits occurred at least once every 60 days for 3 of 3 residents reviewed for physician visits. Resident #62 had diagnoses including congestive heart failure, dementia, and diabetes, and was documented as severely cognitively impaired and dependent on staff for most activities of daily living. Her record showed a nurse practitioner progress note on 12/18/25 and a physician annual wellness visit on 3/31/26, with no documentation of any physician or NP assessment between those dates. The physician stated he used scheduler software to track required visit dates, but acknowledged he currently did not have an NP and had let some visits slip by. Resident #44 had dementia and was seen by an NP on 1/29/26 for a 90-day follow-up visit, then by the physician on 4/20/26 for a federally mandated visit and acute visit. Her record contained no documentation of a physician or NP visit from 1/30/26 through 4/19/26, an 80-day gap. Resident #9 had diagnoses including coronary artery disease and hypertension, with moderately impaired cognition and moderate staff assistance needed for most activities of daily living. Her record showed an NP note on 12/11/25 and a physician federally mandated visit on 2/10/26, with no further documentation of assessment afterward; the physician confirmed the resident should have been seen on 4/16/26 but was not because he was not at the facility. The DON and administrator stated the physician was responsible for seeing residents as required by regulation.
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