Failure to Ensure Timely Physician Visits for Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident with congestive heart failure received timely physician visits as required by federal and state regulations. The facility's policy mandates that residents must be seen by a physician at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter, with the option for alternating visits by a physician extender after the initial visit. Record review showed that the resident was seen by a physician in late November and December, and by a nurse practitioner in January, February, and March. However, there was no documentation of a physician visit in February, as required by the alternating schedule. Interviews with the Nursing Home Administrator revealed that the physician attempted to see the resident on two occasions in January, but the resident was not present due to attending dialysis appointments. The administrator provided a hand-written note indicating attempted visits, but confirmed that only completed visits are documented in the medical record system, and there was no physician visit note available for February. The lack of documentation and absence of a physician visit in February led to the deficiency.