Lack of Physician Documentation for Routine Visits
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment and multiple psychiatric diagnoses had proper physician documentation for routine visits as required by facility policy. The resident's medical record showed physician visits occurred on several dates, but there was a lack of documentation for routine 60-90 day visits between two specific dates. During an interview, the DON confirmed that the physician had seen the resident and signed orders but did not document a note for the visit, and the physician could not recall the reason for this omission. The facility's policy requires residents to be seen by a physician within 30 days of admission, every 30 days for the first 90 days, and at least every 60 days thereafter, with documentation of these visits in the medical record.