Lack of Physician Progress Notes and Documentation After Required Visits
Penalty
Summary
The facility failed to ensure that residents had written, signed, and dated progress notes from their physicians after each required visit. Record reviews for three residents with significant medical conditions, including cerebral infarction, dysphagia, epilepsy, dementia, hemiplegia, hemiparesis, and Parkinson's disease, revealed that their electronic medical records did not contain any documentation of visits or care provided by their primary care service (PCS) providers. The face sheets for these residents indicated that their primary care providers were medical doctors from a local PCS not associated with the facility. Further review of the electronic medical records for the specified periods showed no evidence of PCS provider visits or care for any of the three residents. During an interview, the Director of Nursing confirmed that the medical records for these residents lacked documentation from the PCS providers regarding medical care or visits. This resulted in incomplete resident records and a lack of documented physician review and oversight for the affected residents.