Physician Progress Notes Not Documented in Resident Records
Penalty
Summary
The facility failed to ensure that the physician documented and signed progress notes for each required visit for five out of six residents reviewed for physician visits. For each of these residents, the face sheet identified the same primary physician, and progress notes recorded by an LPN indicated that the physician evaluated the residents on multiple occasions. However, as of the date of review, the electronic medical records for these residents did not contain any physician progress notes corresponding to those visits. During interviews, the Director of Nursing explained that physician visit notes are either documented under assessments or uploaded into the EMR's miscellaneous section, but sometimes the facility must request the physician to send the notes. At the time of the survey, the physician's progress notes for the affected residents were not available in the EMR, and the physician acknowledged that while they attempt to document notes at the time of each visit and complete them during office days, this does not always occur.