Delayed Physician H&P Documentation After Resident Readmission
Penalty
Summary
The facility failed to ensure that a resident's attending physician completed and documented a History and Physical (H&P) assessment within 72 hours following the resident's readmission. Specifically, the medical record review showed that the resident, who was readmitted with diagnoses including toxic encephalopathy, sepsis, and pneumonia, did not have an H&P completed until six days after readmission. The resident's Minimum Data Set indicated severely impaired cognition and a need for substantial to maximal assistance with daily activities. Interviews with the DON confirmed that the H&P was not completed within the required timeframe, and the Nurse Practitioner acknowledged being behind on documentation due to a high workload, resulting in delayed completion and signing of the H&P. Facility policies reviewed indicated that timely documentation and physician visits are required to ensure proper care coordination and communication among the interdisciplinary team, but these were not followed in this instance.