Physician Progress Notes Not Accessible in Medical Record
Penalty
Summary
The facility failed to ensure that physician progress notes for one resident were readily accessible in the medical record. During a review of the resident's admission record and Minimum Data Set, it was found that the resident had been admitted with pneumonia and had moderately impaired cognition, requiring full assistance with activities of daily living. When the Director of Nursing (DON) was interviewed and the resident's medical record was reviewed, the DON was unable to locate completed copies of the physician or nurse practitioner visit notes for the resident. The DON confirmed that these notes should have been present in the medical record, as they are essential for documenting the resident's prognosis, plan of care, and treatment. The facility's policy and procedure on physician services indicated that physician orders and progress notes are to be maintained in accordance with regulatory requirements and facility policy. However, the absence of these notes in the resident's record demonstrated noncompliance with the requirement to maintain complete and readily accessible medical records. This deficiency was identified through direct observation and interview, with no evidence provided that the required documentation was available at the time of the survey.
Plan Of Correction
F 842 Immediate Corrective Action The Medical Records Director immediately contacted the physician's office to request the progress notes for Resident 1. Identification of Others at Risk The Medical Records designee audited all resident charts on 7/24/25 to ensure the physicians' progress notes were in the chart. No other residents were identified with the same deficiency. Process to Prevent Recurrence On 8/1/25, the Medical Records Consultant gave an in-service to the Medical Records staff regarding the policy for physicians' visits, specifically ensuring that the physicians' progress notes are readily accessible to prevent a delay in the delivery of care and necessary services. The Medical Records Designee will audit physicians' progress notes several times a week for six weeks to ensure they are readily available and monthly thereafter for 3 months. All findings will be reported to the Administrator. Monitoring Performance The Medical Records consultant will visit monthly for three months and quarterly thereafter for six months to ensure physicians' progress notes are readily accessible. All findings will be reported to the Administrator. Findings will be reported to the QA committee for further review and recommendations, monthly, for 3 months or until substantial compliance is achieved.