Failure to Ensure Timely Face-to-Face Physician Visits
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a physician or non-physician practitioner conducted a face-to-face visit with a resident at least once every 60 days after the initial 90 days post-admission, as required. The resident in question was admitted with multiple diagnoses, including dementia, diabetes, bipolar disorder, depression, and hepatic encephalopathy, and was assessed as being severely cognitively impaired. Review of the resident's electronic medical record showed no documentation of a physician or non-physician practitioner visit between late February and early June, a period of 93 days, which exceeded the required interval for such visits. The Director of Nursing confirmed that there was no evidence in the facility's records of a face-to-face visit during this time frame. Although the resident received physician services from an outside company and had been hospitalized for part of the period in question, there was still a significant gap where no documented visit occurred. The deficiency was identified through both record review and staff interview, with the DON agreeing that a visit should have taken place within the required timeframe.