Failure to Provide In-Person Physician Examinations for New Admissions
Summary
The facility failed to provide evidence that the physician conducted required in-person examinations for all new admissions, as mandated. Record reviews for four residents admitted from short-term general hospitals revealed that there were no progress notes written by the physician in the electronic health records for any of these residents. Instead, all documented examinations and follow-up visits were completed by a Certified Nurse Practitioner (CNP), with the physician either participating via telemedicine or not mentioned as participating at all. The CNP's notes consistently indicated that evaluations were completed via telehealth or telemedicine, and there was no documentation of the physician being physically present for any of the required visits. Interviews with facility staff, including the Director of Nursing (DON), an LPN, and the CNP, confirmed that the physician typically attended meetings and resident visits virtually due to personal circumstances, specifically his inability to leave his wife. The DON and LPN both stated that the CNP usually conducted resident visits, with the physician participating remotely via telemedicine. The LPN described a process where nurses would initiate a video call with the physician and move the device from room to room, while most communication with the physician was conducted by phone. The CNP verified that visits were conducted virtually if indicated in the progress notes and acknowledged that the physician's participation was not always documented. The CNP also stated that the progress note would specify if the physician or CNP conducted any portion of the visit in-person, but in these cases, there was no such documentation. The lack of in-person physician examinations and insufficient documentation of physician involvement led to the deficiency cited by surveyors.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
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.
A resident with multiple complex medical conditions was not assessed by a physician within the required timeframe after being readmitted from the hospital. Medical records and staff interviews confirmed that the resident had not received a physician assessment since before the readmission, despite being dependent on staff for most care needs.
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.
Failure to Ensure Timely Physician Assessment After Readmission
Penalty
Summary
The facility failed to ensure that a resident was assessed by a physician within the required timeframe following readmission from the hospital. Medical record review showed that the resident, who had multiple diagnoses including morbid obesity, respiratory failure, obstructive sleep apnea, hypothyroidism, bipolar disorder, diabetes mellitus, peripheral vascular disease, anxiety disorder, major depressive disorder, and alcohol dependence, was admitted with hospice services and was dependent on staff for most activities of daily living. Documentation revealed that the resident had not been seen by a physician since a date prior to her hospital readmission, and this was confirmed by the medical director, who acknowledged that the resident should have been assessed within thirty days of readmission but was not.
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