Failure to Ensure Timely Physician Visits and Documentation
Penalty
Summary
A deficiency was identified when a resident, admitted with diagnoses including liver cirrhosis, hypertension, and anemia, was not evaluated by a physician at the required intervals. Review of the resident's clinical records and interviews revealed that the resident had not been seen by a physician in the facility for over a year, despite regular visits from a Nurse Practitioner. The resident reported not having met or seen his physician since admission and expressed a desire to discuss his medical conditions with the physician. The facility's policy and procedure required that the attending physician visit each patient at least once every 30 days for the first 90 days after admission, and at least every 60 days thereafter. Documentation confirmed that only Nurse Practitioner visits were recorded, with no evidence of physician visits as required. The Director of Nursing acknowledged the absence of physician visits and documentation in the resident's progress notes, which did not comply with the facility's policy or regulatory requirements.