Failure to Ensure Timely Physician Visits and Social Services for Residents
Penalty
Summary
The facility failed to ensure that a resident was evaluated by a physician every 60 days and that these visits were documented in the clinical records. Specifically, one resident with diagnoses including liver cirrhosis, hypertension, and anemia had not been seen by a physician in the facility for over a year, as confirmed by both the resident and the Director of Nursing (DON). Although the resident was seen by a Nurse Practitioner on multiple occasions, there was no documentation of a physician visit as required by facility policy, which mandates physician visits at least every 30 days for the first 90 days after admission and at least every 60 days thereafter. The resident expressed that he had not met his physician since admission and wished to do so to discuss his medical conditions. Additionally, the facility failed to provide timely medically-related social services to another resident who required assistance renewing his driver's license for identification purposes at medical appointments. The resident, who is dependent on staff for activities of daily living and has a history of spinal stenosis, quadriplegia, cervicalgia, and major depressive disorder, reported informing the Social Services Director (SSD) of his need for license renewal two weeks prior, but the SSD had not documented any attempts to contact the Department of Motor Vehicles. The facility's social worker job description requires assisting residents in obtaining outside services, including processing forms and applications, but this was not done in a timely manner for the resident.