Failure to Ensure Timely Physician Documentation in Resident Medical Records
Penalty
Summary
The facility failed to ensure that the attending physician responsible for supervising the care of residents documented physician visit progress notes at the time of each required visit. This deficiency was identified for three residents, all of whom were cognitively intact and had various medical diagnoses, including fracture of the left pubis, hypertension, myocardial infarction, cellulitis, obstructive sleep apnea, asthma, spinal stenosis, type II diabetes, and anxiety disorder. For each of these residents, a review of their electronic medical records did not show documentation of a visit from the attending physician during the relevant period. During interviews, the DON stated that some providers entered notes directly into the electronic system while others forwarded notes to be scanned, and was unsure of the attending physician's process. The attending physician, who also served as the facility's Medical Director, reported that due to a recent change in the login system, he had been dictating and handwriting notes to be faxed to the facility for inclusion in the medical record, but was unsure why the documentation was missing for these residents. The facility's policy required timely and pertinent documentation, with notes to be written or entered at the time of the visit or returned to the facility within a week if prepared later. The absence of these notes at the time of the survey constituted the deficiency.