Deficiency in Physician Documentation and Order Signing
Summary
The facility failed to ensure that the responsible physician supervising the care of residents conducted face-to-face visits and wrote progress notes at least once every 30 days. This deficiency was identified for three residents. For Resident #131, the surveyor observed that there were no monthly physician progress notes in the electronic or paper chart, despite the Unit Manager's assertion that the physician visited frequently. The Director of Nursing confirmed the requirement for monthly progress notes but could not explain the absence of documentation. For Resident #7, the physician had not signed the monthly physician orders from December 2023 through June 2024, and there were no progress notes for February and April 2024. The physician stated that he was present in the facility but was not informed by the staff to sign the orders. Similarly, for Resident #77, the physician had not signed the monthly physician orders for the same period. The Unit Manager was unaware of the requirement for the physician to sign the orders, and the physician could not provide further information on the missing signatures. The facility's policy requires that residents be seen by a physician at least once every 30 days for the first 90 days after admission and every 60 days thereafter. The policy also mandates that the physician review the resident's care program, write and sign a progress note for each visit, and sign all orders. The surveyor's findings indicate a failure to adhere to these policies, as evidenced by the lack of documentation and signatures in the residents' medical records.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to ensure required physician visits. A resident with diagnoses including GI hemorrhage, HTN, and TIA/cerebral infarction was admitted and the clinical record lacked evidence of physician visits every 30 days during the first 90 days after admission. The resident stated he/she had not seen the physician, and the DON confirmed the record did not show the required visits.
A resident with severe cognitive impairment and multiple comorbidities, including Alzheimer's disease, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, was not seen face-to-face by a physician within 30 days of admission as required. The resident was evaluated by a PA and later by an NP, but the Nurse Team Lead relied on a tracking report that combined all provider visits (NP, PA, and physician) without distinguishing physician-required visits. As a result, the resident did not appear on the physician-visit list when the physician was on-site and was inadvertently overlooked, a fact confirmed by both the Nurse Team Lead and the Administrator.
A resident with severe cognitive impairment did not have the required face-to-face physician visits documented at the expected interval. The facility’s records showed the last documented physician visit was months earlier, and the DON confirmed the resident should have been seen monthly.
A resident with severe cognitive impairment, significant neurologic diagnoses, and total dependence for ADLs was newly admitted, but the attending physician did not complete or document an initial H&P or any progress notes following admission. Medical record review confirmed there was no evidence the physician had evaluated the resident, even though the physician was in the facility seeing other residents. The MR staff reported that the physician was notified of the admission but no follow-up reminder was made, and the physician acknowledged not following the facility’s physician services policy, which required an evaluation and written physical exam within a defined timeframe after admission.
Missed Required Attending Provider Visits: A resident on hospice care was not documented as being seen face-to-face by an attending provider at least every 60 days. The chart showed a 166-day gap between provider visits, and interviews confirmed the resident’s record lacked documentation for the period in question, despite the provider stating visits were alternated with a NP.
Surveyors found that multiple residents with dementia, behavioral disturbances, and schizoaffective disorder did not have required face-to-face physician visits documented over an extended period. Facility policy required the attending physician to evaluate residents at specified 30- and 60-day intervals and document these visits, but record review showed no physician progress notes or H&Ps authored by the physician for several residents. An NP completed assessments and H&Ps, with the physician signing but not dating at least one document, and the DON and ADM reported that the physician rounded weekly and signed NP notes, yet they could not produce any physician-written progress notes or H&Ps for the residents involved.
Failure to Ensure Required Physician Visits
Penalty
Summary
The facility failed to ensure that physician visits were conducted at least once every 30 days for the first 90 days after admission and at least every 60 days thereafter for one resident. Review of the resident’s clinical record showed an admission date of 2/17/26 and diagnoses that included gastrointestinal hemorrhage, hypertension, and transient ischemic attack/cerebral infarction. The record lacked evidence that the resident was seen by the physician every 30 days during the first 90 days after admission as required by facility policy and applicable regulations. During an interview on 4/12/26, the resident stated that he/she had not seen the physician. During an interview on 4/15/26, the DON confirmed that the clinical record lacked evidence that the resident was seen by the physician as required and stated that all residents should be seen every 30 days for the first 90 days after admission and then every 60 days thereafter.
Failure to Ensure Timely Physician Visit After Admission
Penalty
Summary
The facility failed to ensure that a resident was seen face-to-face by a physician within 30 days of admission, as required. The resident was admitted with multiple significant diagnoses, including Alzheimer's disease, dementia with agitation, diabetes, severe protein-calorie malnutrition, chronic kidney disease, and hypertension, and had severe cognitive impairment per a quarterly MDS assessment. Review of the electronic medical record showed no evidence that the resident had been seen by a physician within the required timeframe. Instead of a physician visit, the resident was seen by a PA and later by an NP shortly after admission. The Nurse Team Lead, who was responsible for tracking when physician regulatory visits were due, used a report from the computer system that listed the last date residents were seen by any provider (NP, PA, or physician). She manually marked which provider conducted the visit and used this list to inform providers which residents needed to be seen. Because the system did not distinguish physician visits from NP/PA visits on the tracking report, the resident did not appear on the physician-visit list when the physician was in the facility, and therefore was not scheduled for a physician visit. Both the Nurse Team Lead and the Administrator confirmed that the resident had not been seen by the physician and that this was an oversight.
Missed Required Physician Visits
Penalty
Summary
The facility failed to ensure that Resident 15 was seen by the physician at the required intervals. The facility’s Physician Visits policy stated that the attending physician must visit residents at least every 30 days for the first 90 days after admission and at least every 60 days thereafter, unless an alternate schedule not exceeding 60 days is established. Resident 15 was admitted to the facility and had a quarterly MDS assessment showing a BIMS score of 3, indicating severe cognitive impairment. Review of Resident 15’s physician visit notes did not show documented evidence of the required physician visits between January and April 2026. During a concurrent interview and medical record review, the DON verified that the last documented face-to-face physician visit for Resident 15 was on 12/30/25 and stated there should have been a monthly physician visit. The Administrator and DON were later informed of and acknowledged the findings.
Failure to Complete and Document Timely Initial Physician Assessment for New Admission
Penalty
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.
Missed Required Attending Provider Visits
Penalty
Summary
Facility staff failed to ensure that Resident #5 was seen face-to-face by an attending provider at least every 60 days. A medical record review showed provider visit notes on 3/4/25, 3/5/25, 3/10/25, 3/12/25, 3/31/25, 4/1/25, 4/8/25, 4/11/25, 4/21/25, 4/28/25, and 6/18/25, but no documented attending provider visits from August 2025 until the next visit on 12/1/25, leaving a 166-day gap between visits. During interviews, the director of clinical operations stated residents must be seen by an attending provider at least every 60 days after admission, and the attending provider stated visits were alternated between him and a NP and sometimes recorded in the physical chart. A follow-up review of the resident’s physical chart still showed no evidence of provider visits during the August-to-December 2025 period, and the provider confirmed the chart lacked documentation for that time.
Failure to Ensure Required Physician Face-to-Face Visits and Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were seen face-to-face by a physician at the required intervals and that the physician documented these visits in the medical record, as required by facility policy. Surveyors determined that four residents did not have physician progress notes or history and physical (H&P) examinations completed by their physician for a one-year period. Facility policy dated 08/2020 required the attending physician to evaluate residents at least every 30 days for the first 90 days after admission and at least every 60 days thereafter, with documentation of these visits in the health record. One affected resident had dementia with agitation and stimulant-induced anxiety disorder, a BIMS score of 8/15 indicating moderate cognitive impairment, and a care plan addressing cognitive impairment and behavioral issues such as throwing items at others, with interventions including monitoring behavior episodes and documenting potential causes. Another resident had unspecified dementia with behavioral disturbance and a care plan for impaired cognitive function, including using yes/no questions to determine needs. For this resident, an NP completed a history and physical, which was signed but not dated by the physician. A third resident had dementia with anxiety, a BIMS score of 15/15 indicating no cognitive impairment, and a care plan for impaired cognitive function with interventions such as identifying oneself at each interaction and maintaining eye contact. The fourth resident had schizoaffective disorder, bipolar type, with a BIMS score of 15/15 and a care plan for mood problems related to bipolar disorder, insomnia, depression, and anxiety, including risk for mood changes related to pain or discomfort and use of anticonvulsant medications for bipolar disorder. Review of the electronic health records for all four residents showed no physician progress notes, assessments, or H&Ps completed by their physician from 3/27/25 to 3/27/26. During interviews, the DON and ADM stated that the residents’ physician rounded on Wednesdays and signed off on NP notes, but they were unable to provide any written physician progress notes or H&Ps authored by the physician, other than the NP’s H&P for one resident that was signed but undated by the physician.
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