Delayed Physician Documentation in Medical Records
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
A deficiency was identified when a physician's progress notes were not present in the resident's electronic medical record on the day the resident was seen. Medical record review showed that several physician visit notes were dated earlier in the month but were not signed or uploaded into the resident's record until several days later. Additionally, one physician note was not signed and uploaded until five days after the visit. During an interview, the physician stated that he typically entered notes within 24 hours and indicated that the delayed notes were not his. The Nursing Home Administrator confirmed these findings during the survey.