Failure to Ensure Timely Physician Progress Notes and Care Review
Penalty
Summary
The facility failed to ensure that the attending physician reviewed the total program of care, including treatments and medications, and completed timely progress notes for all 38 residents reviewed. The Medical Director, who was responsible for seeing approximately 40 residents, did not document or upload progress notes in the electronic health record for any of the residents he visited over a period of several weeks. Staff interviews confirmed that while other providers uploaded their notes within 24 to 48 hours, the Medical Director did not follow this practice, and no progress notes from him were available in the system for the specified timeframe. Staff members, including the CEO, DON, and medical records personnel, all stated that they expected timely documentation of resident visits and care, but acknowledged that this was not occurring for the Medical Director’s visits. The Medical Director stated that his process was to provide handwritten documentation after seeing residents and to upload progress notes every four to six weeks, but also indicated that it was not possible to include a full review of the care program, medications, and treatments in his handwritten notes. The lack of timely and complete documentation was confirmed by multiple staff members and through joint record reviews, which showed no progress notes had been uploaded by the Medical Director during the review period. This deficiency was reported to the state agency due to concerns about the Medical Director’s fulfillment of his medical duties.