Physician Progress Notes Not Timely Entered After Resident Visits
Penalty
Summary
The facility failed to ensure that a physician timely wrote, signed, and dated progress notes at each required visit for one of four residents reviewed. Specifically, for a resident with diagnoses including urinary tract infection, muscle weakness, and cognitive communication deficit, progress notes were entered, signed, and dated significantly after the actual visits occurred. For example, one progress note was entered 27 days after the visit, another 31 days later, and a third 32 days later. These late entries were made by the Medical Director following the resident's readmission and subsequent follow-up care. Clinical record review and staff interviews confirmed that the physician did not comply with the facility's policy and regulatory requirements for timely documentation. The Nursing Home Administrator and DON acknowledged that the required physician documentation was not completed within the specified timeframes for this resident, as mandated by state regulations regarding nursing services, physician services, and clinical records.