Failure to Ensure Timely Physician Visits and Documentation
Penalty
Summary
The facility failed to ensure that a resident received timely physician visits as required. Upon review of the resident's medical record, it was found that the physician's visit notes for the year were missing from the record until the medical records supervisor (MRS) contacted the physician to obtain them. The notes provided showed that the intervals between some physician visits exceeded the required 60-day timeframe, with gaps of 86 and 91 days between visits. The facility's policy requires physician progress notes to be written at each visit, at least every 30 days for the first 90 days after admission and at least once every 60 days thereafter. The deficiency was confirmed through interviews with the MRS and the director of nursing (DON), who acknowledged that the resident was not seen by the physician within the required intervals. The lack of timely physician evaluations was identified through a review of the visit notes and facility policy, and the DON confirmed that residents are to be seen at least once every 60 days with documentation at each visit.