Failure to Ensure Timely Physician Visits and Documentation
Penalty
Summary
The facility failed to ensure that residents were seen face-to-face by their attending physician or nurse practitioner at the required intervals, and that appropriate progress notes were documented in the electronic medical record (EMR). For four residents reviewed, there were significant gaps in physician documentation and visits. One resident with severe cognitive impairment and multiple diagnoses, including diabetes and asthma, had no progress notes from the attending physician for a ten-month period. Another resident, also severely cognitively impaired, lacked both a history and physical (H&P) note upon initial admission and re-admission, as well as progress notes from the attending physician for several months. A third resident, who was cognitively intact and had diagnoses of low back pain and anemia, had an H&P and a single progress note from the attending physician, but there were no physician or nurse practitioner notes for several consecutive months, nor evidence of consistent alternating monthly visits as required. This resident also experienced two hospitalizations, after which the expected H&P documentation upon re-admission was missing. The fourth resident, with moderately impaired cognition and diagnoses including anxiety disorder and anemia, had an H&P and a progress note from the physician, but no further notes from either the physician or nurse practitioner for multiple months, and no evidence of the required visit schedule being followed. Interviews with nursing staff and review of facility policy confirmed that the expectation was for physicians to see new admissions within 24-48 hours, complete H&P documentation, and make regular progress notes during rounds. However, staff were unable to locate the required documentation in the EMR for the residents reviewed, and confirmed that the expected physician visits and notes were not present for extended periods. The facility's policy aligned with state and federal regulations, but was not followed in practice for these residents.