Failure to Schedule and Perform Physician-Ordered GYN Procedure
Penalty
Summary
The facility failed to ensure that a physician-ordered gynecological consult and related procedure were scheduled and performed for a resident with significant medical needs. The resident, who was admitted with multiple diagnoses including limited mobility and cognitive impairment, had a history of fungal rashes in the perineal area that were previously treated and resolved. Despite a physician's order for a gynecological consult and a specific procedure, there was no evidence in the medical record that the order was carried out, and nursing staff were unaware of the order. Interviews with nursing staff confirmed they had not seen or received the order, nor had they observed any ongoing issues in the affected area during their care of the resident. The resident's family member reported not being informed by the facility about the fungal issues or the need for the gynecological procedure, only learning about it during an external gynecologist visit. The family member stated that he had been waiting for almost a month for the facility to schedule the procedure and had not received any updates despite repeated inquiries. The facility administrator acknowledged the delay and lack of communication, citing the procedure's special nature as a reason for the scheduling delay, but provided no timeline or further information to the family.
Plan Of Correction
F684 Quality of Care A) What corrective action(s) will be accomplished for those residents found to have been affected by this practice? a. On was scheduled for at 4pm for Resident #1. B) How will you identify other residents having the potential to be affected by the same practice, and what corrective action will be taken? a. On Director of Nursing/designee completed an audit of physician order to ensure any outsource diagnostic testing has been ordered. C) What measures will be put into place or what systemic changes will you take to ensure that the practice does not reoccur? a. By the Director of nursing/designee to complete education with the nurses to ensure any outsource diagnostic testing has been submitted to the coordinator. b. On education provided to the coordinator to ensure are scheduled timely for outsource diagnostics and transportation if needed. D) How will the corrective actions be monitored to ensure the practice will not reoccur; what quality measures will be put into place? a. Director of nursing/designee will complete audit of residents who have outsource diagnostic testing scheduled in a timely manner and transportation if needed, compliance with federal regulation F684 weekly x4 weeks then monthly for 2 months or until substantial compliance is achieved. b. Findings will be reported monthly at the QA/Risk management meeting until such time substantial compliance has been determined. F 684