Failure to Complete and Document Timely Initial Physician Assessment for New Admission
Summary
The deficiency involves the facility’s failure to ensure that the attending physician conducted and documented a timely initial history and physical (H&P) assessment for a newly admitted resident. The resident was admitted with serious neurological diagnoses, including subarachnoid hemorrhage and cerebral infarction, and had severely impaired cognition, required two-person assistance for ADLs, and was incontinent of bowel and bladder. Review of the medical record for the month following admission showed no documentation that the attending physician evaluated the resident, completed an H&P, or wrote any progress notes. The Medical Records Assistant confirmed that there was no evidence the physician had seen the resident, despite the physician being in the facility and seeing other residents during that period. The Medical Record Director stated that the attending physician was notified of the admission but that no follow-up reminder call was made after the initial notification. The attending physician acknowledged not following the facility’s policy on physician services and visits, explaining that she typically sees residents on specific days of the week and was unsure whether she had been reminded of the admission; she stated that she should have completed the initial assessment and documentation. The DON stated that the physician was supposed to perform a physical examination within three days of admission to identify the resident’s current condition and inform the resident and responsible party of goals, care, and treatment services. The facility’s written policy required the attending physician to perform a patient evaluation, including a written report of the physical examination, within five days prior to admission or within seventy-two hours after admission, which did not occur for this resident.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to document required provider visits. A resident with multiple serious diagnoses, including metabolic encephalopathy, vertebral osteomyelitis, pressure ulcers, MI, and chronic respiratory failure, had provider visits documented only on two dates after readmission, with no April visit note found in the record. The DON stated she was unsure of the required visit schedule, said the MD tracked visits, and could not provide the missing note even though she said the MD had it.
Missed and Delayed Physician Visits: The facility failed to ensure required face-to-face physician visits were completed on time for multiple residents, and several physician notes were missing, delayed, or could not be verified in the EHR. Records showed long gaps between encounters, draft or unverifiable documentation, and residents reporting that facility physicians did not routinely see them.
Physician Face-to-Face Visit Documentation Not Maintained: The facility failed to ensure three residents were seen by the attending physician at least every 60 days. Records for residents with diagnoses including fracture, cirrhosis, anxiety, seizures, and severe intellectual disabilities showed no physician progress note documentation for extended periods, and residents stated they had not seen a physician in months. The ADMN and DON reported the MD made rounds and gave orders, but progress notes were not being sent and there was no written evidence of physician rounds.
Failure to Ensure AP Completed Initial Visit: A resident admitted with malignant melanoma and pneumothorax had an H&P completed and electronically signed by the NP, with no documented evidence that the AP visited upon admission. The ADON confirmed the AP visit was not documented, and the DON stated the H&P should have been conducted by the AP. Facility policy states the initial comprehensive visit may not be performed by an NP, PA, or CNS employed by the facility.
Three residents had incomplete physician documentation in their records. One resident admitted for rehab after sepsis secondary to a UTI had unsigned admission orders, a missing initial H&P in the EMR at review, and a delayed discharge summary signature; two other residents had admission orders signed by nursing but not by the MD, and each had a physician visit note that was signed late. The facility policy required physician orders and progress notes to be maintained per State and Federal regulations.
Failure to Alternate Required Physician Visits: The facility did not ensure required physician visits were alternated between the MD and NP/PA for several residents. Records for residents with conditions including CHF, A-fib, COPD, TIA, Parkinson’s disease, and other chronic diagnoses showed repeated NP-signed physician progress notes without evidence of the required alternation, and the DON confirmed the missing alternating visits.
Failure to Document Required Provider Visits
Penalty
Summary
The facility failed to ensure that Resident 4 was seen face-to-face by a physician or other provider at the required intervals after readmission. Resident 4 was initially admitted and later readmitted with diagnoses including metabolic encephalopathy, osteomyelitis of the vertebra, streptococcus group A, pressure ulcers of the sacral region and right buttock, myocardial infarction, and chronic respiratory failure. Review of the medical record showed provider visits documented on 3/23/26 and 5/26/26, but documentation for an April 2026 physician visit was not found in the record. During interviews on 6/29/26, the DON stated she was unsure how often providers were supposed to see residents, said the providers tracked who needed to be seen, and later stated the MD told her residents were to be seen on admission, at 30 days, and again at 60 days, and that visits could be completed by either the physician or NP. The DON also stated she was unsure whether Resident 4 had been seen on the expected day and that the MD had the April visit note, but she could not provide it and it was not in Resident 4's medical record.
Missed and Delayed Physician Visits
Penalty
Summary
The facility failed to ensure that required face-to-face physician visits were completed at the required frequency for 5 of 12 sampled residents, and that the corresponding physician documentation was completed and maintained in the residents’ medical records. The report identified missed or delayed physician encounters for Residents 1, 2, 3, and 4, along with incomplete or unverifiable documentation in the EHR. The facility policy titled Physician Services, dated June 2022, required residents to be seen by a physician at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter, with a visit considered timely if it occurred no later than 10 days after the due date. For Resident 1, the EHR showed a BIMS score of 14 and the last physician progress note dated 03/16/2026, which was 101 days before the interview. The MRD confirmed that this was the most recent physician note in the record. Resident 1 stated that the most recent physician visit occurred outside the facility on 06/10/2026 and that physicians did not come to see them at the facility except when they first arrived about five years earlier. Review of the resident’s monthly progress notes showed physician encounters on 03/16/2026, 08/19/2025, and 04/15/2025, with gaps of 209 days, 96 days, and 90 days between encounters. The report also noted History & Physical notes with credentials and electronic signatures that could not be verified. For Resident 2, the EHR showed a BIMS score of 11 and the last physician progress note dated 01/19/2026, which was 157 days before the interview. Resident 2 stated they had been seen by a physician about a month earlier for shortness of breath and did not see the facility physician very often. The record included an annual H&P dated 11/21/2025 with completion date, time, and electronic signature that could not be verified, a monthly progress note dated 09/04/2025 with a physician encounter 142 days after the prior note, and another monthly note dated 03/15/2026 that was marked as a draft and had unverifiable completion information. For Resident 3, the EHR showed a BIMS score of 06 and the last physician progress note dated 03/03/2026, which was 114 days before the interview. Resident 3 stated they had not been seen by a physician at the facility since becoming a resident, though they had seen physicians outside the facility several times. The record showed a custodial 30-day visit note dated 05/14/2026 with completion date, time, and electronic signature that could not be verified, and the encounter occurred 72 days after the prior physician note. For Resident 4, the EHR showed a BIMS score of 99, indicating the resident was unable to complete the BIMS. The MRD initially found no physician notes in the EHR, and after a subsequent request the facility produced six physician written notes for dates of service 04/18/2025, 10/08/2025, 12/10/2025, 02/11/2026, 04/08/2026, and 06/10/2026. A custodial 60-day visit note dated 10/08/2025 showed a physician encounter 173 days after the previous physician progress note, and the completion date, time, and electronic signature could not be verified. For Resident 5, the EHR showed a BIMS score of 13 and the last physician progress note dated 03/16/2026, which was 101 days before the interview. After a subsequent records request, the facility produced eight physician written notes for dates of service 02/04/2026, 02/10/2026, 02/13/2026, 02/19/2026, 03/11/2026, 03/16/2026, 05/15/2026, and 06/18/2026. The report stated that physician visit notes were not uploaded into the EHR in a timely manner, limiting clinical staff’s ability to review and respond to the residents’ ongoing medical needs.
Physician Face-to-Face Visit Documentation Not Maintained
Penalty
Summary
The facility failed to ensure that Resident #2, Resident #4, and Resident #16 were seen face-to-face by a physician at least once every 60 days. Record review for Resident #2 showed diagnoses including a right leg fracture, anxiety, and major depression, with a BIMS of 15 indicating no cognitive impairment, but physician progress notes from 10/22/2025 through 06/08/2026 contained no documentation from the primary physician. During observation and interview, Resident #2 stated she had not seen a physician for as long as she could remember. Resident #4’s record showed diagnoses including cirrhosis of the liver and anxiety, with a BIMS of 15 indicating no cognitive impairment, but physician progress notes from 10/22/2025 through 05/06/2026 contained no documentation from the primary physician. During interview, Resident #4 stated he saw the new physician in May but had not seen a physician in months before that. Resident #16’s record showed diagnoses including seizures and severe intellectual disabilities, with a BIMS of 03 indicating severe cognitive impairment, but physician progress notes from 10/29/2025 through 06/08/2026 contained no documentation from the primary physician. The ADMN stated the new Medical Director started in May 2026 and that the MD was making rounds, giving orders, and signing orders, but was not sending documentation and progress notes. The DON stated the MD left at the end of April 2026, made visits, but did not send progress notes, and there was no written evidence of the MD making rounds on residents.
Failure to Ensure AP Performed Initial Comprehensive Visit
Penalty
Summary
The facility failed to ensure that the Attending Physician performed the required comprehensive visit before allowing the Nurse Practitioner to complete the visit for one sampled resident. Resident 1 was admitted on 3/16/2026 with diagnoses including unspecified malignant melanoma of skin and unspecified pneumothorax. The admission record showed the resident was admitted at 8:30 p.m., and the nursing admission assessment documented the admission date. The History and Physical for Resident 1, dated 3/16/2026, indicated the resident had the capacity to understand and make decisions, and the Minimum Data Set dated 4/7/2026 indicated the resident’s cognitive skills for daily decisions were intact. During interview, the ADON stated the History and Physical was done by the NP and that there was no documented evidence in the medical record that the AP came and visited Resident 1 upon admission. The DON stated the History and Physical should be conducted by the AP so the resident could be assessed thoroughly and the initial care plan could be developed. The facility policy titled Physician Services and Visits stated that initial comprehensive visits may not be performed by the PA, NP, or CNS employed by the facility.
Incomplete Physician Authentication and Missing H&P Documentation
Penalty
Summary
Timely physician authentication was not present in the medical records for three residents, and one resident’s initial H&P was missing from the EMR at the time of review. R1 was admitted for subacute rehabilitation and skilled nursing management following hospitalization for sepsis secondary to a UTI. Review of R1’s record showed the initial admission orders entered by nursing on the admission date had no evidence of MD1’s signature, the initial comprehensive H&P was not in the record when first reviewed, and the discharge summary was not electronically signed until much later than the encounter date. The H&P that was later provided was electronically signed and posted after the deficiency was identified, and it contained an incorrect transition-to-SNF date. The ADM and MD1 both described the admission-order process, and MD1 stated he had not been aware of the electronic signature feature until recently. R2 and R3 were both transferred from acute care and admitted to the facility, and their records also showed physician admission orders that were signed by nursing but not signed by MD1. In addition, each resident had a physician visit note that was not signed in a timely manner, with the electronic signature occurring well after the encounter date. The facility policy titled Physician Services stated that physician orders and progress notes were to be maintained in accordance with State and Federal regulations and facility policy.
Failure to Alternate Required Physician Visits
Penalty
Summary
The facility failed to ensure that required physician visits were alternated between the physician and the nurse practitioner or physician assistant for four residents reviewed. The facility policy stated that the physician should assign an alternate physician or physician extender to make visits as appropriate by State law, and that required SNF visits after the initial visit may alternate between personal visits by the physician and visits by a physician assistant, nurse practitioner, or clinical nurse specialist acting within scope and under physician supervision. Resident R4 was admitted with osteoarthritis, CHF, and A-fib, and the record showed physician progress notes signed by the nurse practitioner on 12/8/25 and 1/12/26 without evidence of alternating visits. Resident R8, admitted with A-fib, high blood pressure, and cervical disc disorder with myelopathy, had physician progress notes signed by the nurse practitioner on 10/13/25, 12/18/25, and 2/16/26, also without evidence of alternation. Resident R9, admitted with COPD, TIA, and high blood pressure, had nurse practitioner-signed physician progress notes on 11/24/25 and 1/5/26 without alternating visits. Resident R10, admitted with CHF, A-fib, and Parkinson's disease, had nurse practitioner-signed physician progress notes on 12/8/25, 1/8/26, 1/21/26, 2/16/26, and 3/19/26, again without evidence of alternating visits. During interview, the DON confirmed that R4, R8, R9, and R12's records lacked evidence of alternating visits as required.
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