Failure to Review and Document Residents' Total Program of Care During Required Provider Visits
Penalty
Summary
The facility failed to ensure that physicians and other providers reviewed residents' total programs of care, including skin, pressure injury risk, prevention, and treatment plans at each required visit for three of seven sampled residents. For one resident admitted with a high risk for pressure injury, a stage 2 pressure injury was identified by an APRN, but the care plan was not updated, and no referral to the IWCS or wound assessment was completed until over two weeks later. The physician's regulatory visit note did not address the pressure injury, and the physician was unaware of the issue, having not reviewed prior APRN notes or discussed the resident's skin condition before the visit. The DON confirmed that the provider visit did not accurately review the resident's total program of care as required. Another resident with cerebral palsy and limited range of motion was observed to have new skin issues, including a wound and redness, documented by nursing staff. However, the physician's recertification note did not address these new skin concerns. A third resident admitted with a deep tissue pressure injury to the left knee had physician orders for wound care, but the physician's admission note did not address the wound or the treatment plan, instead documenting that exposed skin areas were clear. These findings demonstrate repeated failures to review and document residents' care programs, particularly regarding skin and wound care, during required provider visits.