Failure to Ensure Timely Physician Visits and Documentation
Penalty
Summary
The facility failed to ensure that a resident's primary physician conducted face-to-face visits and documented progress notes at least once every 60 days, as required for Medicaid recipient residents. Review of the medical record for one resident revealed a gap in Physician Progress Notes, with no documentation found between 10/29/24 and 2/25/25. The resident, who was admitted with diagnoses including asthma and had moderately impaired cognition as indicated by a BIMS score of 8 out of 15, was observed asleep in bed during the survey. The facility's policy requires physician visits at specified intervals, but the required documentation was missing for this resident. Interviews with facility staff, including an LPN/Unit Manager, confirmed that the physician is expected to visit regularly and document in the electronic medical record. However, when the surveyor attempted to contact the physician's office, the physician was unavailable, and no additional information was provided by the LNHA or DON. The deficiency was identified through observation, interview, and record review, and was found to be inconsistent with both facility policy and regulatory requirements.