Failure to Ensure Physician Review and Documentation of Resident’s Total Program of Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a physician reviewed a resident’s total program of care, including medications and treatments, and documented an evaluation of the resident’s condition at required visits. Resident 53, admitted with unsteadiness on feet, difficulty in walking, and muscle weakness, had nursing notes indicating that a physician saw the resident on two occasions. A nursing note dated 12/4/25 documented that the resident was seen by a physician, and another nursing note dated 1/13/26 documented that the physician reviewed labs and medications and answered questions, with a plan to continue monitoring. However, the physician progress note for the 1/13/26 visit could not be located in the resident’s medical record, and there was no documented physician evaluation of the resident’s condition and total program of care, including medications and treatments, and no documented decision about the continued appropriateness of the current medical regimen. During interviews, the HIM Director reported that one of the facility physicians does not write or dictate any medical records for the residents he sees, requiring the facility to call the physician’s office to request progress notes, and stated that it was hard to track resident records because the physician did not write in the resident’s medical record. The DON explained that the facility sends a form with the resident for the physician to write what was done at the appointment and that, if more detailed notes are needed, staff must call the physician’s office to obtain progress notes, which are then scanned into the resident’s record. The DON also stated that the physician sends back a worksheet with orders and that it is difficult to obtain progress notes from this physician. These practices resulted in missing physician documentation for Resident 53’s visit and a lack of evidence that the physician reviewed and evaluated the resident’s total program of care as required.
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