Untimely Physician Documentation and Failure to Implement Treatment Orders
Penalty
Summary
Physicians and NPs failed to complete and upload progress notes and orders to the medical record in a timely manner and did not ensure that care plans and treatment orders were fully reviewed and implemented. For one resident admitted after a fall with rib fractures, a nephrology NP consultation performed on 1/13/26 was not uploaded and available to staff until 1/15/26, and the DON confirmed that this consultant had been uploading her own reports days after seeing residents, with recommendations not being communicated. The unit manager described a new process in which the nephrologist enters their own orders and uploads their own consults, and also stated that the facility had not been receiving anything directly from nephrology for about two months. The facility NP reported that she does not review the MAR, was unaware that the resident had a nephrology consult, and therefore did not identify a medication error until it was brought to the DON’s attention by the surveyor. For the same resident, the attending physician began a history and physical note on 1/12/26 but did not complete and sign it until 1/13/26, making it available about 36 hours after initiation. That note documented reconciliation of medications and included an order to discontinue a 10 mg dose of Oxybutynin while continuing two 5 mg tablets, and to start Trospium for overactive bladder; however, these changes were not implemented, and the resident continued on a duplicate Oxybutynin dose until 1/21/26. For another resident, the attending physician entered an effective date indicating the resident was seen on 1/12/26, but the note was not created and available in the record until 1/14/26, delaying access to any associated orders. The DON acknowledged that there were multiple physician notes from prior months that were uploaded days after completion and that the attending physician involved no longer worked at the facility.
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