Failure to Submit Required Information for Imaging Study
Penalty
Summary
Maplewood Nursing and Rehab Center failed to ensure that necessary information was submitted to obtain an imaging study for one resident, identified as Resident R4. Resident R4 was admitted to the facility with a complex medical history, including a left basal ganglia intraparenchymal hemorrhage, status post craniectomy, stroke, cognitive communication deficit, and other conditions. On April 16, 2024, a neurosurgery consult recommended a 'stealth CT ordered for prosthetic manufacturing.' However, the facility did not submit the required medical information to the resident's insurance company to approve the necessary imaging studies. The facility's documentation revealed that on May 7, 2024, a nurse aide attempted to contact the insurance company multiple times to check on the approval status of the stealth CT scan, but the insurance company had not received the required information. Further attempts on May 24, 2024, to obtain approval for a CT scan of the abdomen/pelvis were also denied due to a lack of medical information. Interviews with the insurance company confirmed that no medical information had been submitted for Resident R4, and the facility was unable to provide evidence of submission. The facility's Administrator and Assistant Director of Nursing confirmed these findings during an interview on December 11, 2024.
Plan Of Correction
Immediate corrective action: Placed a call to POA regarding care conference and follow up on resident's procedure. Discussed that medical records were able to retrieve additional information and will ask for a new script to get the scan necessary for Hershey medical. On 12.12, authorization for release of information was signed and faxed to Hershey medical Department of Neurosurgery for medical record release of information for insurance purposes. Appointment and scan approved by insurance. Stealth scan to take place on January 10th @10am. Family aware. House wide corrective action: Auditing all current residents to ensure follow up appointments/testing has been completed as requested. NHA or designee will complete weekly audits x4 to ensure timely appointments and follow-up if applicable. QA meeting will determine the need for continued monthly auditing.