Observations
A review of seven patient records was conducted on May 24, 2017. Based on this review, the facility failed to complete the annual physical examination to include the annual reevaluation in two of seven patient records reviewed .
Patient # 4 initial physical examination was completed on November 13, 2015. The annual physical examination was due to be completed by November 13, 2016 but was not documented as completed until December 1, 2016.
Patient # 6 initial physical examination was completed on November 24, 2014. The annual physical examination was due to be completed by November 24, 2015 but was not documented as completed until December 21, 2015.
These finding were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director met with the nursing supervisor and medical team to review the citation. All staff were trained on June 7, 2017 on the services due report in SMART the electronic data base for the medical records. Moving forward all patients will be scheduled one month in advance of their annual physical date. The facility director and nursing supervisor will check the services due report on a weekly basis and ensure that physicals are scheduled. |