Physician Failed to Review Resident's Total Program of Care
Penalty
Summary
The facility failed to ensure that a physician reviewed a resident's total program of care as required. Specifically, for one resident with diagnoses including dementia, anemia, and a history of stroke, there were significant fluctuations and a notable decrease in weight over a short period. Despite these changes, the clinical record and progress notes did not document that the weight loss was verified for accuracy or addressed by the physician or registered dietician. A nurse practitioner note and a physician's 60-day recap note also failed to mention any evaluation or intervention regarding the resident's weight loss. Interviews with the medical director revealed reliance on nursing staff to communicate weight changes, but during physician recap visits, all available information was reviewed. However, the documentation did not reflect that the physician had reviewed or addressed the resident's weight loss. The nursing home administrator confirmed that the facility did not ensure the physician reviewed the resident's total program of care, as required by state regulations.