Missing Physician Progress Notes for Resident
Summary
The facility failed to ensure physician progress notes were completed for Resident 90 for the months of February, March, and April 2026. During record review, the Medical Records Director reviewed Resident 90’s physician progress notes and stated there were no notes for those three months, adding that physicians usually fax the notes. The Minimum Data Set Nurse also reviewed the record and stated she could not find the physician progress notes for the last three months, and stated that physician progress notes should be completed monthly. The facility’s policy on Physician Visits stated the attending physician must visit residents at least once every thirty days for the first ninety days after admission and then at least every sixty days thereafter, and must complete relevant documentation at each visit. The facility’s policy on Physician Progress Notes stated the attending physician must write, sign, and date the physician progress notes upon each visit.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A provider failed to ensure required physician visits were alternated with PA visits for several residents under SNF stays. Four residents had provider encounters documented primarily by a PA, with no documentation of the required physician visits after admission or during the certification period. The administrator stated she believed a PA could complete all standard visits, and the PA stated she usually saw residents in the nursing home for their medical care and visits.
The facility failed to ensure a physician completed the initial comprehensive visit for two residents. One resident had diagnoses including depression, muscle weakness, and difficulty walking, and another had diagnoses including HTN, hyperlipidemia, and insomnia. Their clinical records lacked documentation of the required physician visit, and the DON confirmed the omission.
Physician Visit Frequency Not Met: A resident with CVA, DM, and major depressive disorder was not seen face-to-face by the attending physician at least every 60 days, and the physician documented only one visit over about 4 months while an NP saw the resident multiple times. The resident reported seldom seeing the physician and needing to discuss left knee pain, while the DON confirmed the physician’s limited visits and the facility policy required regular physician evaluations and documentation.
A facility failed to ensure a physician completed the initial comprehensive in-person visit within the required timeframe and continued in-person visits at least every 60 days for two residents. In both cases, an NP completed the initial visit and monthly visits were documented, but the first physician face-to-face visit occurred months after admission.
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 Visit Schedule Not Followed for SNF Residents
Penalty
Summary
The provider failed to ensure required physician visits were alternated between personal visits by the physician and visits by the physician assistant after the physician’s initial comprehensive visit for residents under SNF stays. Record review showed that four sampled residents had SNF stays during the review period, and their provider visits were completed by PA C without documentation of the required physician involvement. Resident 8 had multiple PA C visits documented, but there was no documentation of a physician medical visit within the last year. Resident 29 was seen by PA C for the initial certification visit, second certification visit, and final 90-day certification visit, with no documentation of any physician visit since admission. Resident 4 had two SNF stays during the review period and was seen by PA C for multiple provider visits, while physician documentation was limited to a hospital follow-up and an acute issue, not the required alternating physician visits for the SNF stay. Resident 43 had a SNF stay and was seen by PA C for the initial certification visit, second certification visit, and 90-day certification visit, with no documentation of a physician visit or examination after admission. The administrator stated she believed a PA could see all residents for standard medical visits and was not aware that a physician had to conduct the initial visit and every other 30-day physician visit for residents under SNF stays. PA C stated she usually saw residents in the nursing home for their medical care and visits, and that a physician was available on call if needed.
Failure to Ensure Initial Physician Visits Were Completed
Penalty
Summary
The facility failed to ensure that a physician completed the initial comprehensive visit for two residents. Resident R1 was admitted to the facility and had an MDS dated 5/26/26 showing diagnoses of high depression, muscle weakness, and difficulty walking, but the clinical record did not include documentation that the initial comprehensive physician visit was completed. Resident R2 was also admitted to the facility, had an MDS showing diagnoses of high blood pressure, hyperlipidemia, and insomnia, and the clinical record likewise lacked documentation that the initial comprehensive physician visit was completed. During an interview on 7/17/26 at 2:21 p.m., the DON confirmed that the facility failed to ensure a physician completed the initial comprehensive visit for both residents.
Physician Visit Frequency Not Met
Penalty
Summary
The facility failed to ensure that one sampled resident was evaluated face-to-face by the physician at least every 60 days and that those visits were documented in the clinical record. Resident 48 was admitted with diagnoses including cerebral infarction, DM, and major depressive disorder. The resident’s H&P indicated capacity for medical decision making, and the MDS dated 5/8/2026 indicated cognition was intact and that the resident was dependent on staff for toileting hygiene and dressing. During interview, Resident 48 stated she seldom saw her physician and reported needing to speak with the physician about left knee pain. Record review and interview with the DON showed that Resident 48 was seen by an NP on multiple occasions from 1/11/2026 through 7/3/2026, but was not seen by the physician during those visits. The DON stated the physician saw Resident 48 once that year on 3/3/2026, which was approximately 120 days after the prior visit. The DON also stated the physician should visit at least once a month and could alternate visits with the NP, and that the physician would document findings in the progress notes after each visit. The facility’s Physician Visits policy required the attending physician to visit at least every 60 days after the first 90 days, and the Facility Assessment indicated attending physicians were required to evaluate patients within 72 hours of admission and at least every 30 days following the initial visit or based on medical needs.
Delayed Physician In-Person Visits
Penalty
Summary
The facility failed to ensure that a physician completed the initial comprehensive in-person visit within 30 days of admission and then completed in-person visits at least once every 60 days thereafter for 2 of 7 sampled residents. Resident #1 was admitted on 02/09/26, and the record showed a nurse practitioner completed the initial comprehensive in-person visit on 02/11/26 with monthly in-person visits through June 2026, but the first in-person physician visit did not occur until 07/01/26, almost five months after admission. Resident #6 was admitted on 01/22/26, and the record showed a nurse practitioner completed the initial comprehensive in-person visit on 01/28/26 with monthly in-person visits through March 2026, but the first in-person physician visit did not occur until 04/11/26, almost three months after admission.
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.
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