Failure to Maintain Timely Physician Progress Notes
Penalty
Summary
A deficiency was identified when the attending physician failed to provide written, signed, and dated progress notes following each required visit for one resident. The resident, who had a recent history of falls and required stitches, did not have timely physician progress notes documented in the electronic medical record. Review of the resident's records revealed gaps in physician documentation, with the most recent notes either missing or not uploaded for several months. Staff interviews confirmed that only psychiatric and ARNP notes were present, and the Director of Nursing acknowledged the absence of physician notes for an extended period, stating that this was not optimal. Further review of facility policy indicated that physician progress notes are required to be maintained for each resident and must reflect each visit, including the physician's signature and date. The deficiency was further substantiated when the DON confirmed that summaries in the record did not constitute physician notes and that the lack of documentation for several months was unacceptable. The missing notes were later found in the medical records department, which had a staffing vacancy, but this did not mitigate the initial failure to maintain timely and complete physician documentation as required by facility policy.