Failure to Complete Required Provider Assessment After Resident Refusal
Penalty
Summary
A provider failed to complete a comprehensive assessment and review of a resident's total program of care during a required visit. The resident, who was admitted for rehabilitation services following a hospital stay for multiple medical conditions, expressed dissatisfaction with the initial provider's bedside manner and felt her concerns were not adequately addressed. During the provider's first visit, the resident became upset and asked the provider to leave before a physical exam or full assessment could be completed. The provider documented that the assessment was incomplete and noted the resident's refusal to continue the visit. Following this incident, the resident did not receive a subsequent visit from another provider to complete the required assessment, history and physical, or to make recommendations for ongoing care. Staff attempted to arrange for the resident to be seen by other providers, but the resident either refused or the attempts were unsuccessful. As a result, the resident's comprehensive care needs were not fully evaluated or addressed during her stay, contrary to facility policy and regulatory requirements.