Physician Documentation Lacking for Resident's Care Review
Summary
Facility staff failed to ensure that the physician's documentation reflected a comprehensive review of a resident's total care. Specifically, a resident with reported concerns regarding dietary needs and medication management related to irritable bowel syndrome (IBS) did not have a documented medical diagnosis of IBS in their medical record. The resident was evaluated by a gastroenterologist, who recommended discontinuing two medications, starting two new ones, and implementing a dairy-free diet based on IBS symptoms. These recommendations were communicated to the facility and confirmed by the facility's physician. However, the physician's subsequent progress note only mentioned that the resident had seen a gastroenterologist and started new medication, with a recommendation for follow-up, but did not document the IBS diagnosis or address the resident's dietary needs. During an interview, the physician stated disagreement with the IBS diagnosis but acknowledged failing to document his clinical judgment or an alternative treatment plan. This lack of documentation contributed to the facility's failure to implement the recommended dietary orders and update the resident's plan of care.
Penalty
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The facility failed to ensure timely NP documentation, signatures, and dates for required visits for two residents. One resident with multiple comorbidities, including DM, morbid obesity, and a right foot abscess, had NP progress notes for a bedside assessment of high-risk sexual behavior and a visit for DM and obesity entered and signed days to weeks after the actual encounters. Another resident with dementia, HTN, MDD, and DM had NP notes documenting being the recipient of another resident’s inappropriate behavior and a visit for a rash also entered and signed after the dates of service. The NP confirmed during interview that these were late entries and that provider visits were not being documented and signed on the days residents were seen due to her being behind on documentation.
A physician's progress notes for a resident on hospice care inaccurately documented ongoing diabetic monitoring and treatment, despite the absence of blood glucose orders, diabetic labs, or diabetic medications. The physician was unaware of the resident's hospice status and used a generic note for diabetic residents, while nursing staff did not communicate any concerns about blood sugar management.
The facility failed to ensure timely signing of physician progress notes for three residents, with delays ranging from several days to weeks. The DON confirmed these delays during a complaint investigation.
A facility failed to ensure timely follow-up by a physician for a resident with elevated sodium levels. The resident, with multiple health issues, had a lab report showing abnormal sodium levels, which the MD reviewed but did not act upon until days later. Interviews revealed a lack of awareness and follow-up, despite facility policy requiring timely medical assessments.
The facility failed to ensure timely signing of physician and NP visit notes, affecting three residents. One resident, cognitively intact, had multiple diagnoses and experienced delays in note signing after assessments. Another resident, also cognitively intact, had a 13-day delay in note signing. A third resident, with impaired cognition, faced delays ranging from three to 13 days. The ADON confirmed issues with the Medical Director, who resigned due to these documentation problems.
A facility failed to ensure timely signing of progress notes by an NP, affecting three residents with various medical conditions. The NP admitted to not charting during visits and was instructed she had 48 hours to complete notes, leading to delays of up to three days in signing.
Untimely NP Documentation and Signatures for Resident Visits
Penalty
Summary
The deficiency involves the facility’s failure to ensure that physician and NP visits were signed and dated in a timely manner at each required visit for two residents. For one resident with diagnoses including right foot abscess, major depressive disorder, morbid obesity, hypertensive retinopathy, pulmonary embolism, insomnia, intellectual disability, essential primary hypotension, and diabetes mellitus, the medical record showed late-entry NP progress notes. One late entry documented a bedside assessment for high-risk sexual behavior and was recorded for a date in January but not authored and signed until early February. Another late entry documented a provider visit related to diabetes and morbid obesity, also recorded for an earlier date but not authored and signed until several days later. For a second resident with insomnia, dementia, essential primary hypertension, major depressive disorder, and diabetes mellitus, similar late-entry NP documentation was identified. One late entry described the resident as the recipient of another resident’s inappropriate behavior and was recorded for a January date but not authored and signed until early February. Another late entry documented a visit for a rash, with the note recorded for one date and authored and signed two days later. During an interview, the NP confirmed that she created and signed the late-entry progress notes for both residents on a later date than when the residents were seen and acknowledged that provider visits were not being documented and signed on the days the residents were actually seen, stating she was behind on documentation due to workload.
Physician Progress Notes Failed to Reflect Resident's Actual Care and Condition
Penalty
Summary
A deficiency was identified when a physician's progress notes for a resident failed to accurately reflect an evaluation of the resident's condition and program of care. The resident, who had diagnoses including neurocognitive disorder with Lewy bodies, type 2 diabetes with unspecified complications, anxiety, and hypertension, was admitted to hospice care and had severely impaired cognition, requiring total assistance for daily activities. The care plan included interventions for terminal illness and end-of-life comfort measures. However, the physician's notes repeatedly referenced blood sugar monitoring and continuation of a diabetic treatment plan, despite the absence of any blood glucose orders, diabetic labs, or diabetic medications for the resident during the review period. Record review and staff interviews confirmed that no blood glucose checks or diabetic labs had been ordered or performed, and the resident was not receiving diabetic medications. The physician acknowledged that the progress notes were a generic statement used for diabetic residents and admitted to being unaware that the resident was on hospice services. The physician also stated that nursing staff had not communicated any concerns regarding the resident's blood sugars, and he had overlooked the hospice status noted on the resident list.
Physician Note Signing Delays
Penalty
Summary
The facility failed to ensure that physicians signed progress notes at the time of service for three residents. Resident #51, who had multiple diagnoses including emphysema and dementia, had a physician visit on 01/27/25, but the progress note was not signed until 02/09/25. The physician claimed to sign notes immediately after completion, but this was contradicted by the Director of Nursing (DON) who confirmed the delay. Similarly, Resident #52, with diagnoses such as chronic kidney disease and rheumatoid arthritis, had two physician visits on 09/10/24 and 10/07/24, with both progress notes signed only on 10/19/24. Resident #60, diagnosed with conditions including pulmonary embolism and chronic pain syndrome, had a physician visit on 10/21/24, with the note signed on 11/16/24. The DON verified these delays, which were discovered during a complaint investigation.
Failure to Ensure Timely Physician Follow-Up for Elevated Sodium Levels
Penalty
Summary
The facility failed to ensure timely and adequate follow-up by the physician for a resident's care needs, specifically regarding elevated sodium levels. Resident #19, who had multiple diagnoses including dementia, anxiety, and chronic kidney disease, had a lab report showing an abnormal sodium level of 156 mEq/L, which was outside the normal range. The lab results were reported to the facility, and the Medical Director (MD) reviewed them but did not provide any new orders or follow-up until several days later. The illegible handwriting on the lab report was confirmed to be the MD's signature, dated the day after the lab results were received. Interviews with the MD and the Nephrology Nurse Practitioner (NNP) revealed a lack of awareness and follow-up on the elevated sodium levels. The MD was unable to recall reviewing the lab results or providing any subsequent treatment, and the NNP was not informed of the elevated sodium level until several days later. The facility's Director of Nursing (DON) confirmed that the lab report was placed in the MD's folder for review, but no action was taken until days later, despite the facility's policy requiring timely medical assessments and information sharing. This deficiency was identified during a complaint investigation.
Untimely Signing of Provider Visit Notes
Penalty
Summary
The facility failed to ensure that physician and nurse practitioner visit notes were signed in a timely manner, affecting three residents. Resident #06, who was cognitively intact, had multiple diagnoses including myocardial infarction and diabetes mellitus. The resident was assessed by the facility physician and a nurse practitioner, but their notes were not signed until several days after the assessments. Similarly, Resident #34, also cognitively intact, had her physician's progress notes signed 13 days after the assessment. Resident #60, who had impaired cognition, experienced delays in the signing of physician notes ranging from three to 13 days after assessments. The Assistant Director of Nursing (ADON) confirmed the issue of untimely documentation and noted concerns related to the facility's Medical Director, who had given notice of resignation due to these documentation issues. The facility's policy on charting and documentation, dated July 2017, requires that documentation of procedures and treatments include specific details such as the date and time, which was not adhered to in these cases.
Delayed Signing of Progress Notes by NP
Penalty
Summary
The facility failed to ensure that the physician and nurse practitioner's (NP) progress notes were timely written and signed at each visit, affecting three residents. Resident #30, who had moderate cognitive impairment and multiple diagnoses including malignant neoplasm and chronic kidney disease, had a progress note dated 11/12/24 that was not signed until 11/13/24. Resident #32, with severe cognitive impairment and conditions such as Parkinson's disease and diabetes mellitus, had multiple progress notes with delays in signing, ranging from one to three days after the date of service. Resident #75, who had a significant change in condition and was unable to complete a BIMS due to communication difficulties, also experienced delays in the signing of progress notes, with some notes signed two days after the date of service. The NP involved, identified as NP #80, admitted during an interview that she did not chart her visits while seeing the residents. She reported that upon being hired, she was instructed by her manager that she had up to 48 hours to complete and sign her progress notes after seeing the residents. This practice led to the deficiency, as the progress notes were not signed and completed at the time of the visit for the residents involved.
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