Failure to Document Original Physician Progress Notes at Required Visits
Penalty
Summary
The facility failed to ensure that an attending physician or designee wrote, signed, and dated original progress notes at each required visit for one resident. The resident was admitted with diagnoses including type 2 diabetes mellitus, dementia, and anxiety disorder. A Minimum Data Set dated 12/15/2025 documented that the resident had no cognitive impairment in decision-making and required varying levels of staff assistance for bathing, dressing, oral care, toileting, and personal hygiene. Health Status Notes from early August 2025 showed that the resident complained of abdominal pain. During a concurrent interview and record review with the nurse practitioner (NP) on 2/9/2026, Attending Progress Notes dated across multiple months were examined. The notes for 7/3/2025, 8/4/2025, 9/5/2025, 10/6/2025, 11/7/2025, 12/7/2025, and 1/26/2026 were found to be identical in content, each stating that the resident had no complaints and a non-tender abdomen, with only the date at the top changed. The NP acknowledged photocopying the previous month’s progress note because the NP believed there were no changes in the resident’s condition. This practice conflicted with the facility’s Physician Services policy, which required physician orders and progress notes to be maintained in accordance with current OBRA regulations and facility policy. The report stated that this failure had the potential to result in overlooked changes in the resident’s health status and compromised physician oversight of the resident’s total program of care.
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