Physician Progress Notes Failed to Reflect Resident's Actual Care and Condition
Penalty
Summary
A deficiency was identified when a physician's progress notes for a resident failed to accurately reflect an evaluation of the resident's condition and program of care. The resident, who had diagnoses including neurocognitive disorder with Lewy bodies, type 2 diabetes with unspecified complications, anxiety, and hypertension, was admitted to hospice care and had severely impaired cognition, requiring total assistance for daily activities. The care plan included interventions for terminal illness and end-of-life comfort measures. However, the physician's notes repeatedly referenced blood sugar monitoring and continuation of a diabetic treatment plan, despite the absence of any blood glucose orders, diabetic labs, or diabetic medications for the resident during the review period. Record review and staff interviews confirmed that no blood glucose checks or diabetic labs had been ordered or performed, and the resident was not receiving diabetic medications. The physician acknowledged that the progress notes were a generic statement used for diabetic residents and admitted to being unaware that the resident was on hospice services. The physician also stated that nursing staff had not communicated any concerns regarding the resident's blood sugars, and he had overlooked the hospice status noted on the resident list.