Lack of Physician Documentation and Delegation in Admission Examinations
Penalty
Summary
The facility failed to provide evidence that the physician did not delegate tasks to non-physician providers that were required to be completed personally by the physician. For four residents admitted from short-term general hospitals, medical record reviews showed that there were no progress notes written by the physician, who also served as the facility's Medical Director, documenting participation in the admission examinations. Instead, admission evaluations were completed by a Certified Nurse Practitioner (CNP) via telehealth or telemedicine, with no documentation of the physician's involvement in these assessments. Interviews with facility staff, including the Director of Nursing (DON), an LPN, and the CNP, confirmed that the physician often participated in meetings and resident visits via telephone or telemedicine due to personal circumstances. However, there was no documentation in the residents' records to verify the physician's participation in the admission process. The CNP also stated she was unaware of any law prohibiting her from completing initial visits via telemedicine, and verified that visits were conducted virtually if indicated in the progress notes.