Failure to Schedule Cardiology Follow-Up
Penalty
Summary
The facility failed to ensure that a resident received appropriate treatment and care as per physician orders. The deficiency was identified through a review of facility policies, clinical records, and staff interviews. The facility's policy on 'Resident Rights' mandates that residents be informed of their medical conditions and participate in their care planning and treatment. Additionally, the 'Medication and Treatment Orders' policy requires that treatment orders be consistent with safe and effective practices. However, the facility did not adhere to these policies for one resident. The resident in question was admitted with diagnoses including high blood pressure, arthritis, and coronary artery disease. A physician's order dated shortly after admission required a follow-up appointment with cardiology one month after a stent placement. Upon review of the resident's clinical record, it was found that no cardiology follow-up appointment had been scheduled or attended. Interviews with the scheduler and the Director of Nursing confirmed that the appointment had not been made, indicating a failure to comply with the physician's order and facility policies.
Plan Of Correction
Immediate Action: On 2/5/2025 while the DOH surveyors were present, the appointment with cardio for resident R1 was scheduled for 2/6/2025 and transport was arranged. Resident R1 had no ill effects from the appointment being after the date it was to be scheduled. Education: Education was provided to all licensed nursing staff on the process for making appointments listed on the hospital discharge orders. Audits: All admission charts are reviewed during the AM clinical meeting. During review appointments will be audited to ensure they are made timely in accordance with the discharge orders. Audits will be completed weekly times 2 weeks and monthly times 1 month.