Failure to Ensure Physician Review of Total Care for Ventilator‑Dependent Residents
Summary
The deficiency involves the facility’s failure to ensure that the attending physician reviewed each ventilator‑dependent resident’s total program of care, including medications, treatments, wound care, and abnormal laboratory results, at required visits. For one ventilator‑dependent resident with chronic respiratory failure, cerebral infarction, and multiple pressure ulcers (including one facility‑acquired), the face sheet identified a pulmonologist as the attending physician. A wound note dated 03/27/2026 ordered daily and PRN treatments to multiple ulcers, while physician orders signed by the pulmonologist on the same date specified different treatment frequencies (twice daily for some wounds and three times daily for others). The treatment administration record showed staff followed the pulmonologist’s orders, but there was no documented evidence that the pulmonologist, as attending physician of record, reviewed or reconciled the discrepancies between the wound specialist’s recommendations and the physician’s own treatment orders. Interviews and wound documentation for this resident showed ongoing wound problems that were not addressed by the attending physician. The wound care nurse reported that the resident had multiple wounds, including a right buttock wound with purulent discharge and signs of infection, and that the wound care specialist verbally recommended treatment orders during weekly wound rounds, which the nurse transcribed into physician orders and used to update the care plan. The nurse also stated that, due to excessive drainage, wound treatments had been increased from twice daily to three times daily for at least a week. However, the wound physician assistant stated they had not recommended treatments more than once daily and indicated they would have recommended hospitalization if they had known the resident required wound care more than once daily for excessive drainage. Subsequent medical notes contained no evaluation or discussion by the attending physician of these wound care changes or the wound team’s recommendations. For a second ventilator‑dependent resident with chronic respiratory failure, hypoxic ischemic encephalopathy, and multiple unhealed, facility‑acquired stage 2 and 3 pressure ulcers, the face sheet also listed the pulmonologist as the attending physician. This resident had stagnant, unhealing sacral and buttock ulcers with ongoing serosanguinous drainage documented in multiple wound notes. Laboratory results over time showed progressively abnormal values, including elevated WBC counts and low hemoglobin and hematocrit. Nurse practitioner notes documented an infected right buttock ulcer, initiation of IV Zosyn, and subsequent discontinuation of the antibiotic before completion, as well as additional wound treatment orders (Santyl and Silvadene). Despite these findings and repeated wound notes describing stagnant, draining ulcers, there was no documented evidence that the pulmonologist, as attending physician of record, reviewed or addressed the increasingly abnormal lab values or the ongoing reports of stagnant, draining, unhealing pressure ulcers. The pulmonologist’s monthly progress note referenced the presence of pressure ulcers but did not address their unhealing status or recent lab results. Interviews with facility leadership and clinicians revealed confusion and inconsistency regarding who was actually serving as attending physician for ventilator‑dependent residents. The DON stated that nursing staff were responsible for documenting wound characteristics daily and referring any changes to the medical doctor. A nurse practitioner reported that three NPs sometimes covered episodic concerns on the ventilator unit and that wound care specialists were responsible for evaluating wounds, addressing stagnant unhealing wounds, and ordering treatments. The medical director stated that the pulmonologist was assigned as attending physician for ventilator‑dependent residents and that facility clinicians, including the medical director and pulmonologist, were responsible for ensuring wound care specialists addressed the care plan and that orders were carried out. In contrast, the pulmonologist stated they were only responsible for respiratory care, were not the attending physician for any residents, and were not responsible for non‑respiratory treatments. The administrator similarly stated the pulmonologist was not the attending physician for ventilator‑dependent residents and was unaware of why the pulmonologist was listed as attending on the residents’ face sheets. This lack of clarity and failure to ensure that an attending physician reviewed and coordinated the residents’ total care programs led to the cited deficiency under 10 NYCRR 415.15(b)(2)(iii).
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with multiple chronic conditions was transferred to the hospital and did not return, yet an after-visit summary later documented that the medical director examined the resident in the facility, including detailed vital signs and discussion of numerous diagnoses. The resident had already left and was subsequently discharged, but the physician still billed for doctor and nursing home care for that date, and payment was processed. Facility leadership confirmed the resident was not present when the visit was documented and acknowledged that the physician’s documentation was inaccurate, contrary to facility policy requiring objective and accurate charting.
The facility failed to ensure timely NP documentation, signatures, and dates for required visits for two residents. One resident with multiple comorbidities, including DM, morbid obesity, and a right foot abscess, had NP progress notes for a bedside assessment of high-risk sexual behavior and a visit for DM and obesity entered and signed days to weeks after the actual encounters. Another resident with dementia, HTN, MDD, and DM had NP notes documenting being the recipient of another resident’s inappropriate behavior and a visit for a rash also entered and signed after the dates of service. The NP confirmed during interview that these were late entries and that provider visits were not being documented and signed on the days residents were seen due to her being behind on documentation.
A physician's progress notes for a resident on hospice care inaccurately documented ongoing diabetic monitoring and treatment, despite the absence of blood glucose orders, diabetic labs, or diabetic medications. The physician was unaware of the resident's hospice status and used a generic note for diabetic residents, while nursing staff did not communicate any concerns about blood sugar management.
The facility failed to ensure timely signing of physician progress notes for three residents, with delays ranging from several days to weeks. The DON confirmed these delays during a complaint investigation.
A facility failed to ensure timely follow-up by a physician for a resident with elevated sodium levels. The resident, with multiple health issues, had a lab report showing abnormal sodium levels, which the MD reviewed but did not act upon until days later. Interviews revealed a lack of awareness and follow-up, despite facility policy requiring timely medical assessments.
The facility failed to ensure timely signing of physician and NP visit notes, affecting three residents. One resident, cognitively intact, had multiple diagnoses and experienced delays in note signing after assessments. Another resident, also cognitively intact, had a 13-day delay in note signing. A third resident, with impaired cognition, faced delays ranging from three to 13 days. The ADON confirmed issues with the Medical Director, who resigned due to these documentation problems.
False Physician Documentation and Billing for Non-Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the physician accurately documented and provided services as recorded in the medical record, resulting in false documentation and billing for services not rendered. A long-term resident with multiple diagnoses, including heart failure, pulmonary fibrosis, dysphagia, memory problems, and dependence on staff for ADLs, was admitted to the facility and later transferred to the hospital for a change in condition, without returning to the facility. The resident’s actual date of leaving the facility was documented as mid-month, and the facility stopped billing at the end of that month. A progress note later documented that the resident was not returning to the facility following the hospital transfer. Despite the resident’s non-return and discharge status, an after-visit summary dated approximately two weeks after the hospital transfer documented that the medical director examined the resident in the facility, including a detailed discussion of multiple medical conditions and specific vital signs. An insurance statement showed that the physician billed for doctor and nursing home care on that date, and payment was processed. The AD confirmed the resident should not have been billed after the end of the month, and the DON acknowledged that the physician’s documentation was sometimes inaccurate and verified that the resident was not in the facility when the after-visit was completed. Email correspondence from the physician confirmed he had documented seeing the resident at the facility on that date even though she had transferred to the hospital with no return, contrary to the facility’s policy requiring objective, complete, and accurate documentation in the medical record.
Untimely NP Documentation and Signatures for Resident Visits
Penalty
Summary
The deficiency involves the facility’s failure to ensure that physician and NP visits were signed and dated in a timely manner at each required visit for two residents. For one resident with diagnoses including right foot abscess, major depressive disorder, morbid obesity, hypertensive retinopathy, pulmonary embolism, insomnia, intellectual disability, essential primary hypotension, and diabetes mellitus, the medical record showed late-entry NP progress notes. One late entry documented a bedside assessment for high-risk sexual behavior and was recorded for a date in January but not authored and signed until early February. Another late entry documented a provider visit related to diabetes and morbid obesity, also recorded for an earlier date but not authored and signed until several days later. For a second resident with insomnia, dementia, essential primary hypertension, major depressive disorder, and diabetes mellitus, similar late-entry NP documentation was identified. One late entry described the resident as the recipient of another resident’s inappropriate behavior and was recorded for a January date but not authored and signed until early February. Another late entry documented a visit for a rash, with the note recorded for one date and authored and signed two days later. During an interview, the NP confirmed that she created and signed the late-entry progress notes for both residents on a later date than when the residents were seen and acknowledged that provider visits were not being documented and signed on the days the residents were actually seen, stating she was behind on documentation due to workload.
Physician Progress Notes Failed to Reflect Resident's Actual Care and Condition
Penalty
Summary
A deficiency was identified when a physician's progress notes for a resident failed to accurately reflect an evaluation of the resident's condition and program of care. The resident, who had diagnoses including neurocognitive disorder with Lewy bodies, type 2 diabetes with unspecified complications, anxiety, and hypertension, was admitted to hospice care and had severely impaired cognition, requiring total assistance for daily activities. The care plan included interventions for terminal illness and end-of-life comfort measures. However, the physician's notes repeatedly referenced blood sugar monitoring and continuation of a diabetic treatment plan, despite the absence of any blood glucose orders, diabetic labs, or diabetic medications for the resident during the review period. Record review and staff interviews confirmed that no blood glucose checks or diabetic labs had been ordered or performed, and the resident was not receiving diabetic medications. The physician acknowledged that the progress notes were a generic statement used for diabetic residents and admitted to being unaware that the resident was on hospice services. The physician also stated that nursing staff had not communicated any concerns regarding the resident's blood sugars, and he had overlooked the hospice status noted on the resident list.
Physician Note Signing Delays
Penalty
Summary
The facility failed to ensure that physicians signed progress notes at the time of service for three residents. Resident #51, who had multiple diagnoses including emphysema and dementia, had a physician visit on 01/27/25, but the progress note was not signed until 02/09/25. The physician claimed to sign notes immediately after completion, but this was contradicted by the Director of Nursing (DON) who confirmed the delay. Similarly, Resident #52, with diagnoses such as chronic kidney disease and rheumatoid arthritis, had two physician visits on 09/10/24 and 10/07/24, with both progress notes signed only on 10/19/24. Resident #60, diagnosed with conditions including pulmonary embolism and chronic pain syndrome, had a physician visit on 10/21/24, with the note signed on 11/16/24. The DON verified these delays, which were discovered during a complaint investigation.
Failure to Ensure Timely Physician Follow-Up for Elevated Sodium Levels
Penalty
Summary
The facility failed to ensure timely and adequate follow-up by the physician for a resident's care needs, specifically regarding elevated sodium levels. Resident #19, who had multiple diagnoses including dementia, anxiety, and chronic kidney disease, had a lab report showing an abnormal sodium level of 156 mEq/L, which was outside the normal range. The lab results were reported to the facility, and the Medical Director (MD) reviewed them but did not provide any new orders or follow-up until several days later. The illegible handwriting on the lab report was confirmed to be the MD's signature, dated the day after the lab results were received. Interviews with the MD and the Nephrology Nurse Practitioner (NNP) revealed a lack of awareness and follow-up on the elevated sodium levels. The MD was unable to recall reviewing the lab results or providing any subsequent treatment, and the NNP was not informed of the elevated sodium level until several days later. The facility's Director of Nursing (DON) confirmed that the lab report was placed in the MD's folder for review, but no action was taken until days later, despite the facility's policy requiring timely medical assessments and information sharing. This deficiency was identified during a complaint investigation.
Untimely Signing of Provider Visit Notes
Penalty
Summary
The facility failed to ensure that physician and nurse practitioner visit notes were signed in a timely manner, affecting three residents. Resident #06, who was cognitively intact, had multiple diagnoses including myocardial infarction and diabetes mellitus. The resident was assessed by the facility physician and a nurse practitioner, but their notes were not signed until several days after the assessments. Similarly, Resident #34, also cognitively intact, had her physician's progress notes signed 13 days after the assessment. Resident #60, who had impaired cognition, experienced delays in the signing of physician notes ranging from three to 13 days after assessments. The Assistant Director of Nursing (ADON) confirmed the issue of untimely documentation and noted concerns related to the facility's Medical Director, who had given notice of resignation due to these documentation issues. The facility's policy on charting and documentation, dated July 2017, requires that documentation of procedures and treatments include specific details such as the date and time, which was not adhered to in these cases.
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