Failure to Ensure Timely Physician Documentation at Each Visit
Penalty
Summary
A deficiency was identified when the facility failed to ensure that a physician wrote, signed, and dated progress notes at each required visit for a resident. Clinical record review showed that the resident, who was admitted for a seven-day respite stay with diagnoses including C. difficile, diabetes, and high blood pressure, was seen by a wound doctor who provided specific wound care orders. However, the wound note was entered as a late entry several days after the visit, and the corresponding physician orders were also entered on the same later date. Interviews with staff, including the Director of Nursing, confirmed that the physician did not timely document progress notes at each visit as required. The resident was discharged on the same day the late entry and orders were recorded. This failure to ensure timely physician documentation was found for one of two residents reviewed during the survey.