§483.30(b) Physician Visits
The physician must-
§483.30(b)(1) Review the resident's total program of care, including medications and treatments, at each visit required by paragraph (c) of this section;
§483.30(b)(2) Write, sign, and date progress notes at each visit; and
§483.30(b)(3) Sign and date all orders with the exception of influenza and pneumococcal vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications.
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Observations:
Based on staff interviews, review of facility policy and review of clinical records, it was determined that the facility failed to ensure that the resident's physician orders were accurate for 1 out of 16 residents reviewed (Resident R12).
Findings include:
Review of the facility policy, "Attending Physician Responsibilities," with a revision date of August 2025 indicated that attending physicians shall be the primary practitioners responsible for providing medical services, and coordinating the healthcare of each resident in the facility. Continued review of the policy indicated that each attending physician will be responsible for the following which included, but not limited to, accepting responsibility for initial and subsequent resident care; supporting discharges and transfers; providing appropriate care, and providing appropriate, timely, and pertinent documentation. The policy also indicated that the attending physician will seek, provide and analyze information regarding a resident's current status, recent history, and medications and treatments to enable safe, effective continuing care, and to support facility compliance with regulations, and care standards. Continued review of the policy also indicated that in consultation with facility staff, the physician will verify that treatments and services, including rehabilitation services, are medically necessary and appropriate in accordance with relevant criteria.
Review of Resident R12's September 2025 physician orders included the following diagnosis: obesity, hypertension (high blood pressure); chronic pain; depression (a mood disorder that causes a persistent feeling of sadness and loss of interest); anxiety (intense, excessive and persistent worry and fear about everyday situations); muscle weakness, and osteoarthritis (the most common form of arthritis, characterized by joint pain and stiffness).
Continued review of the September 2025 physician order included a physician's order dated March 12, 2025, and monthly thereafter, for the resident to have supervised leave of absence (LOA) visits. "Resident may go on LOA supervised with meds."
Review of the resident's nursing notes indicated that on May 6, 2025 at 11:26 p.m. the resident returned from her leave of absence for the day, and reported to nursing staff that she spilled hot tea on her thighs. Review of a progress note completed by the nurse practitioner on May 7, 2025, at 9:12 a.m. indicated that the resident had sustained 2nd degree burns on both thighs, as the result of the resident's spilling hot tea on her thigh.
Review of a nursing note dated May 28, 2025 at 3:33 p.m. indicated that the resident was off the nursing unit on a leave of absence, and was found on the floor in her independent living apartment after she fell from her motorized scooter. The nursing note indicated that the resident was home alone, and was eventually found by her husband on the floor of her apartment when her returned home.
Review of a nursing note on September 20, 2025 at 5:29 p.m. indicated that the resident returned from her leave of absence off the nursing unit, and was observed by nursing staff as having slurred speech, difficulty making sentences, and her eyes closing while the resident was speaking with staff.
During an interview with the Director of Nursing (DON) on September 25,2025 at 9:30 a.m. and the Nursing Home Administrator, the DON regarding the above referenced incidents that occurred when the resident was on supervised leave of absence, per the current physician's order, the DON explained that the physician's order was incorrect, as the resident did not need supervision when she is off the nursing unit.
During an interview with the resident's attending physician (Employee E4) on September 22, 2025 at 12:22 p.m. the physician confirmed that the physician order for supervised leave of absence for the resident that had been ordered since March 2025, was incorrect. The attending physician explained that the resident did not have to be supervised when she is on leave of absences. During the interview, the physician also confirmed that physician orders are reviewed monthly by the nurse practitioner and the attending physician.
28 Pa. Code 211.5. (f)(i) Medical records
| | Plan of Correction - To be completed: 10/03/2025
Resident R12's order was clarified with medical provider and changed to independent with leave of absence rather than supervised.
DON provided education to medical providers in regards to orders, reviewing orders for accuracy and signing orders.
An audit was conducted on all residents of Woolman House with their Leave of Absence Orders to assure accuracy.
The interdisciplinary team are reviewing all new resident's batch orders for accuracy.
All orders will continue to be verified by the medical provider, initially, as needed and monthly.
Medical records/Designee will audit medical records to assure the orders were reviewed monthly by a medical provider.
DON/Designee will report if there are any issues with orders at our Quality Assurance and Performance Improvement (QAPI) meetings, for at least three quarters.
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