SMQT Nursing and Physician Services 4 — Questions and Answers
Question 1: A surveyor discovers that a facility allows nursing staff to take verbal orders from family members claiming to relay physician instructions. This practice violates which standard?
- Physician orders must be received directly from the authorized practitioner, not through intermediaries (Correct answer)
- Family members are prohibited from participating in care planning
- Orders must always be written, never verbal
- Nursing staff cannot communicate with families about medical treatment
Correct answer: Physician orders must be received directly from the authorized practitioner, not through intermediaries
Verbal and telephone orders must be received directly from a licensed practitioner; relay through family members is not a valid order mechanism and creates serious patient safety risks.
Question 2: During a medication pass observation, a surveyor notes a nurse administering a medication that does not appear on the current Medication Administration Record. The nurse states the physician called in a change. What is the immediate concern?
- The order was not properly documented before administration, creating a medication safety risk (Correct answer)
- The nurse should have refused to administer any unwritten order
- This is acceptable if the nurse documents after administration
- The physician should be present for any medication change
Correct answer: The order was not properly documented before administration, creating a medication safety risk
Medications must not be administered before verbal orders are received, recorded, and authenticated; administering without an MAR entry represents a medication safety and documentation deficiency.
Question 3: A facility's staffing schedule shows that an RN is on duty for only one 8-hour shift per day, with LPNs covering the remaining 16 hours. This arrangement is:
- Non-compliant — an RN must be on duty 24 hours per day, 7 days per week (Correct answer)
- Compliant as long as the RN is available by phone during LPN-only shifts
- Compliant if the facility has fewer than 60 beds
- Non-compliant only if a resident suffers harm during an LPN-only shift
Correct answer: Non-compliant — an RN must be on duty 24 hours per day, 7 days per week
42 CFR §483.35 requires SNFs to have a registered nurse on duty 24 hours a day, 7 days a week, with a limited exception only for facilities with a waiver.
Question 4: Under SMQT standards, when a physician determines that a required interval visit is medically unnecessary for a stable resident, what documentation is required?
- The physician must document in the medical record that the visit was not medically necessary (Correct answer)
- No documentation is needed if the resident is clinically stable
- The DON must authorize the skipped visit in writing
- A second physician must concur before any visit can be skipped
Correct answer: The physician must document in the medical record that the visit was not medically necessary
Federal regulations allow a physician to skip a required interval visit for a stable resident, but the decision and rationale must be documented in the medical record.
Question 5: A surveyor interviews a resident who states she has not seen a doctor in four months. The medical record shows the last documented physician visit was 62 days ago. What should the surveyor do?
- Reconcile the record with the resident's account and investigate whether documentation is missing or the visit did not occur (Correct answer)
- Accept the medical record as accurate since it is an official document
- Cite a deficiency immediately based solely on the resident's statement
- Dismiss the resident's statement as unreliable due to cognitive concerns
Correct answer: Reconcile the record with the resident's account and investigate whether documentation is missing or the visit did not occur
Surveyors must triangulate information from interviews, observations, and records; a discrepancy warrants further investigation rather than immediate citation or dismissal.
Question 6: Which of the following would be cited as a deficiency in physician services rather than nursing services?
- Failure of the physician to sign a written plan of care at the required interval (Correct answer)
- A nurse failing to transcribe a physician order correctly
- An aide performing a task without nurse supervision
- The facility not providing 24-hour licensed nurse coverage
Correct answer: Failure of the physician to sign a written plan of care at the required interval
Physicians are required to sign care plans at specified intervals; failure to do so is a physician services deficiency distinct from nursing documentation or staffing issues.
Question 7: In a nursing facility, what is the regulatory significance of the term 'attending physician' versus 'medical director'?
- The attending physician is responsible for the individual resident's medical care; the medical director oversees the facility's overall medical program (Correct answer)
- The medical director is the attending physician for all residents without personal physicians
- Both roles are interchangeable and can be held by the same person without restriction
- The attending physician must be board-certified while the medical director has no such requirement
Correct answer: The attending physician is responsible for the individual resident's medical care; the medical director oversees the facility's overall medical program
These are distinct roles: the attending physician manages individual resident care, while the medical director coordinates the medical care program facility-wide and liaises with administration.
SMQT Nursing and Physician Services 4
A surveyor discovers that a facility allows nursing staff to take verbal orders from family members claiming to relay physician instructions.
This practice violates which standard?