Failure to Maintain Timely Physician Visit Documentation in Resident Records
Penalty
Summary
The facility failed to ensure that physician visit notes were made part of the resident's medical record, as required by accepted professional standards. A resident with a diagnosis of hypertension, who was cognitively intact, reported not having seen the attending physician during her approximately three-month stay and had only been seen by the APRN. Clinical record review confirmed that there was no documented evidence of the attending physician's visits in the resident's medical record, despite multiple visits by the APRN. The resident expressed concerns about her medical condition, specifically discoloration in her legs, and reported dissatisfaction with the response from facility staff. Interviews with facility staff revealed uncertainty regarding the frequency and documentation of physician visits. The attending physician admitted to using his own EMR system and acknowledged that he had not uploaded visit notes to the facility's system for about a year, citing being busy as the reason for the delay. The lack of timely and proper documentation of physician visits in the resident's medical record constituted a failure to safeguard resident-identifiable information and maintain accurate medical records in accordance with professional standards.