Failure to Schedule and Perform Physician-Ordered Procedure
Penalty
Summary
The facility failed to ensure that a physician-ordered procedure was scheduled and performed for one resident. The resident, who had significant cognitive impairment and required substantial to maximal assistance with hygiene and toileting, had a history of fungal rashes that were treated and resolved. A physician order for a gynecological consult and a specific procedure was documented, but there was no evidence that the procedure was scheduled or completed. Interviews with nursing staff revealed they were unaware of the order, and there was no documentation indicating the procedure had been arranged. The resident's family member reported not being informed about the resident's condition or the scheduling of the ordered procedure, despite repeated inquiries to the facility's administrator. The administrator acknowledged the delay, attributing it to the special nature of the procedure and the need for additional coordination, but was unable to provide a scheduled date. This lack of follow-through resulted in the resident not receiving timely, physician-ordered care as required by regulation.
Plan Of Correction
N201 Right To Adequate and Appropriate Health Care A) What corrective action(s) will be accomplished for those residents found to have been affected by this practice? a. On [date] was scheduled for [procedure] for Resident #1 at 4pm. 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 [date], the Director of Nursing/designee completed an audit of physician orders 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 [specific actions] 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 an audit of residents who have outsource diagnostic testing scheduled in a timely manner and transportation if needed, compliance with federal regulation N201 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.