Failure to Ensure Timely Physician Face-to-Face Visits
Penalty
Summary
The facility failed to ensure that a physician conducted a face-to-face visit with a resident at least once every 60 days, as required by facility policy. Review of the resident's records showed that the last physician note was dated 1/28/2025, and there were no subsequent notes or documentation of a physician visit in the electronic medical record or the resident's chart. The Assistant Director of Nursing (ADON) confirmed that the resident, who was classified as custodial, had not been seen by a physician since that date, despite the expectation that such residents are to be seen every two months. The resident involved had a history of Type II Diabetes Mellitus, heart failure, and hypertension, and was assessed as having severely impaired cognitive skills and being dependent on all activities of daily living. The facility's policy required physician visits at least every 30 days for the first 90 days after admission and at least every 60 days thereafter. The deficiency was identified through interviews and record reviews, which confirmed the absence of required physician visits and documentation.