Failure to Complete Required Physician Visits Within First 90 Days of Admission
Penalty
Summary
The facility failed to ensure that required physician visits were completed at least once every 30 days during the first 90 days of admission for two residents. For one resident, who had multiple complex diagnoses including anemia, heart disease, diabetes, and severe cognitive impairment, there was no documented evidence of a face-to-face physician visit at the 30-day and 60-day marks after admission. The only recorded physician visit was on the date of admission, with subsequent visits by physician extenders, but a gap of 41 days occurred without a documented visit by either the physician or extenders. During this period, the resident experienced a seizure and was sent to the emergency room, with no immediate notification to the responsible party or physician documented in the records. Another resident, also with severe cognitive impairment and multiple psychiatric and medical diagnoses, did not have documented face-to-face physician visits as required. The resident was seen by a nurse practitioner twice shortly after admission and by the physician once, but then there was a 43-day gap without a documented visit. During this time, the resident exhibited significant behavioral issues, including aggression, medication refusals, and was ultimately transferred to the hospital for behavioral decompensation and refusal of care. Medication administration records showed frequent refusals, and nursing notes documented escalating behavioral problems. Interviews with facility staff revealed a lack of clarity regarding the required frequency of physician visits in the first 90 days post-admission. Staff described that the physician and extenders visited weekly, but there was no consistent process to ensure that all required visits were completed and properly documented. Staff turnover and issues with uploading physician visit documentation into the electronic chart were also cited as contributing factors to the deficiency.