§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 clinical record review and interviews with staff, it was determined that the facility did not ensure that a physician wrote, signed, and dated progress notes at each visit for one of two residents reviewed (Resident R1).
Findings include:
Review of the clinical record indicated Resident R1 was admitted to the facility on 10/10/25, with diagnoses that included Clostridium difficile (C. diff - highly contagious bacterium that causes diarrhea and colitis), diabetes, and high blood pressure. Resident R1 was on respite (provides short-term relief for primary caregivers, giving them time to rest, travel, or spend time with other family and friends) stay for seven days.
Review of the clinical record indicated Resident R1 was seen by the wound doctor on 10/13/25, with the following orders:
Wound #1 Left, Plantar Foot: Cleanse Wound. Cleanse with 0.125% Dakin's Solution - and pat dry. Pack undermining, areas and wound bed with kling, cutting only once and leaving tail end visible out of wound bed. Cover with ABD and wrap with kerlix, and secure with tape. Change daily and prn.
Wound #2 Right Buttock gluteus maximus: Cleanse Wound. Cleanse with warm soap and water (gentle scrub) - and pat dry. Use house stock barrier cream. Perform every shift and prn.
Review of the progress notes reveal the wound note was entered as a late entry on October 17, 2025, at 4:08 p.m.
Review of the physician orders indicated wound care orders were entered on 10/17/25. Resident R1 discharged from the facility on 10/17/25.
During an interview on 11/19/25, at 12:40 p.m. the Director of Nursing confirmed the facility failed to ensure that a physician timely wrote, signed, and dated progress notes at each visit for one of two residents reviewed (Resident R1).
28 Pa. Code: 211.12(d)(5) Nursing services.
28 Pa. Code: 211.2(a) Physician services.
28 Pa. Code: 211.5(f) Clinical records.
| | Plan of Correction - To be completed: 12/10/2025
Disclaimer:
Preparation and submission of this Plan of Correction does not constitute an admission of agreement by the provider of the truth of the facts alleged or the correctness of the conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and submitted solely because of requirements under the State and Federal law.
F0711 Physician Visits- Review Care/Notes/Order
Corrective Action for those residents found to have been affected by the deficient practice:
R1 was discharged from the facility on 10/17/2025 and the facility is unable to correct what occurred prior to discharge.
How the facility identified other residents having the potential to be affected by the same deficient practice:
To identify residents who have the potential to be affected, the Director of Nursing/designee will review current residents that have received in-house wound care consultations in the last 14 days, to ensure the physician's documentation was received timely. Corrections will be made as needed.
Measures put in place for systemic changes to ensure that the deficient practice will not recur:
To prevent recurrence, the Director of Nursing/designee will reeducate the in-house wound care consultant regarding timely documentation requirements for residents that receive consultation.
How the facility plans to monitor their performance to make sure that the solutions are sustained:
To monitor and maintain compliance, the Director of Nursing/designee will review current residents that receive in-house wound care on a weekly basis for 4 weeks and monthly for 2 months to ensure timely consultant documentation is received. Corrections will be made as needed.
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