Failure to Complete Timely Initial Physician Visits for Two Residents
Penalty
Summary
The facility failed to ensure that the attending physician conducted an initial comprehensive visit within the first 30 days after admission for two residents admitted under Medicare Part A&B. Both residents, one with multiple diagnoses including arthritis, atrial fibrillation, hyperlipidemia, dementia, nutritional deficiency, and a femur fracture, and another with end stage renal disease, diabetes mellitus, morbid obesity, dependence on renal dialysis, hypertension, muscle weakness, major depressive disorder, and a history of falling, were admitted from the hospital for short-term stays. Upon review, both residents' charts contained blank History and Physical (H&P) pages, indicating that the required physician assessments had not been completed, signed, or dated as of the time of the survey. The Assistant Director of Nurses (ADON) acknowledged that the initial comprehensive physician visit must occur within 30 days of admission and that the facility's policy requires physician visits within 72 hours of admission, at least every 30 days for the first 90 days, and then at least every 60 days thereafter. Despite multiple notifications to the physicians via fax and phone calls regarding the overdue visits, the required documentation remained incomplete. The ADON confirmed that the facility's policy and procedure regarding physician visits was not followed for these two residents.