Failure to Complete Timely Admission History and Physicals
Penalty
Summary
The facility failed to ensure that the attending physician completed and documented a History and Physical (H&P) within 72 hours of admission for two residents. For the first resident, who was admitted with diagnoses including primary generalized arthritis, syncope, and chest pain, the H&P was completed seven days after admission, exceeding the required timeframe. This resident had moderate cognitive impairment and required varying levels of assistance with daily activities. The Medical Records Director confirmed that the H&P was not completed within the required 72-hour window. For the second resident, admitted with Parkinson's disease, encephalopathy, and low back pain, the H&P was documented as a late entry and was signed nine days after admission. This resident also had moderate cognitive impairment and required assistance with daily care. The facility's policy requires that a completed and signed H&P be present in the medical record within 72 hours of admission, and the Director of Nursing or designee is responsible for auditing new admission charts to ensure compliance. The failure to complete timely H&Ps resulted in incomplete medical records for both residents.