Physician Failed to Complete Required Assessment After Resident Readmission
Penalty
Summary
The facility failed to ensure that a resident's attending physician conducted an initial comprehensive assessment following the resident's readmission. Specifically, after being readmitted, the resident—who had diagnoses including cognitive communication deficit, generalized muscle weakness, and dementia—did not have a History and Physical (H&P) completed by the attending physician within the required timeframe. The only H&P available in the resident's record was from a prior hospitalization, and there was no documentation of a new, facility-based assessment after readmission. Interviews with the Medical Records Director and the Director of Nursing confirmed that the physician did not provide a current H&P after the resident's return, as required by facility policy. The Director of Nursing stated that the physician is supposed to physically see the resident and complete a comprehensive assessment to establish a baseline for care. The absence of this assessment delayed the establishment of the resident's current health status, which is essential for guiding care and services.