Failure to Provide Timely Physician Visits During Initial Admission Period
Penalty
Summary
The facility failed to ensure that a resident received timely physician visits as required during the first 90 days of admission. Specifically, documentation and interviews confirmed that the resident was not seen by the attending physician every 30 days, as mandated by both facility policy and federal regulations. The Medical Records Director verified that there was no evidence of a physician or nurse practitioner visit in the resident's medical chart for two consecutive months. The Medical Director acknowledged challenges in maintaining the required visit schedule due to difficulties in finding practitioners to assist at the facility. The resident in question was admitted with multiple diagnoses, including diastolic heart failure, sleep apnea, and peripheral vascular disease, and had moderate cognitive impairment as indicated by a BIMS score of 12. During interviews, the resident expressed uncertainty about the frequency of physician visits, and the DON confirmed the expectation for monthly visits during the initial 90-day period. The lack of documented visits for November and December was substantiated through record review, confirming the deficiency in meeting required physician visit intervals.