Physician Failed to Address Hospital Discharge Recommendations After Resident Readmission
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a physician reviewed a resident's total plan of care at each required visit. Specifically, after a resident was hospitalized and subsequently readmitted, the attending physician documented a follow-up note acknowledging the recent hospital stay but did not address the hospital's recommendation for a transdermal fentanyl patch to manage the resident's ongoing back pain. The discharge summary from the hospital, which included this recommendation, was present in the resident's medical record but was not acted upon by the physician during the first post-readmission visit. Interviews with both the attending physician and the medical director confirmed that the expectation was for physicians to review the entire plan of care, including discharge summaries and any recommendations or medication changes, upon a resident's readmission. Both acknowledged that the fentanyl patch recommendation was missed and not incorporated into the resident's care plan, and the facility did not identify this oversight until it was brought to their attention during the survey.