Lack of Physician Progress Notes After Resident Visits
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's physician reviewed care and provided written, signed, and dated progress notes after each required visit. The resident, who was admitted with diagnoses including delusional disorders, major depressive disorder, and dementia, had a primary care provider (PCP) not directly associated with the facility but with admitting privileges. Review of the resident's electronic medical record revealed an absence of physician notes documenting visits, with only a single provider note dated several months prior available. The Director of Nursing confirmed that while the PCP did visit the resident occasionally, no documentation of these visits was left or provided for the resident's medical record.