Failure to Ensure Timely Physician Visits After Admission
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident was evaluated by a physician at least once every 30 days for the first 90 days following admission, as required. The resident, who was admitted with diagnoses including cellulitis of both lower limbs, hypertension, and generalized muscle weakness, was only seen by her physician once since admission. Clinical records confirmed that after the initial physician visit, subsequent visits were conducted by a Physician Assistant rather than the physician, and there was no documentation of physician visits for the required months. During interviews, the resident expressed concern about not seeing her physician and wanted to discuss her ongoing high blood pressure. Facility leadership, including the ADON and DON, acknowledged that the physician had not complied with the required visit schedule and that documentation of physician visits was missing for several months. The facility's policy also specified that the attending physician must visit patients at least once every 30 days for the first 90 days after admission, which was not followed in this case.