Failure to Timely Document Physician/Extender Progress Notes
Penalty
Summary
The facility failed to ensure that Physician or Physician Extender progress notes were entered into the clinical record in a timely manner for one resident. Review of the electronic health record (EHR) for this resident, who was admitted with a diagnosis including cerebral infarction (stroke), showed no Physician or Physician Extender notes since December 2024. During interviews, the Nurse Practitioner responsible for the resident's care admitted to not providing notes in the medical chart, acknowledging that notes should be entered at the time of the visit. The Director of Nursing confirmed that the facility's expectation is for clinical notes to be written within 24 hours of the visit, and agreed that no such notes were present in the EHR for the resident in 2025 until the issue was identified. Facility policy requires that physician orders and progress notes be maintained in accordance with OBRA regulations and facility policy.