Failure to Ensure Timely and Accurate Physician Documentation and Medication Review
Penalty
Summary
The facility failed to ensure that the attending physician for a sampled resident conducted a review of the resident's medications at each required visit. Review of the facility's policy indicated that the physician should review the resident's total program of care, including medications, at each visit. However, examination of the resident's medical record revealed that the physician's progress notes consistently listed the same medications across multiple visits, despite documented changes in the resident's medication regimen throughout the year. Nursing progress notes and interdisciplinary team documentation showed that new medications and dosage changes were ordered at various times, but these updates were not reflected in the physician's progress notes. Additionally, the facility did not ensure that the physician wrote, signed, and dated a progress note at each required visit, nor that these notes were present in the resident's medical record. The medical records supervisor confirmed that there were no physician progress notes for the resident in either the hard copy or electronic medical record for the year in question until the physician was contacted and asked to provide them. The physician acknowledged that he had not sent any visit progress notes to the facility and that his notes were stored in his office system, which the facility did not have access to. Upon receiving the physician's notes, it was found that all notes for the year were created, documented, reviewed, and signed on the same day, well after the actual visit dates. This resulted in discrepancies regarding when the notes were performed and documented, and the progress notes did not accurately reflect the resident's current medication regimen at the time of each visit.