Failure to Arrange Timely ENT Referral Following Physician Orders
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice by not arranging a timely appointment with an ENT specialist as ordered. The resident, who had a history of traumatic subdural hemorrhage and dysphonia, had a physician order dated 02/18/2025 requesting referral to a private physician for evaluation of persistent hoarseness. This referral was denied based on internal guidelines, and there was no documented notification to the DON or NP regarding the denial. Subsequently, a nurse practitioner noted on 03/05/2025 that a referral to a local ENT should be made, but there was no evidence that this appointment was scheduled at that time. Interviews revealed that the staff responsible for scheduling appointments was not aware of the need for an ENT referral until 04/10/2025, when the resident presented with shortness of breath. The DON confirmed that there was no system in place to cross-check nurse practitioner progress notes with physician orders, which contributed to the delay in scheduling the necessary specialist appointment. The lack of communication and follow-through on the referral orders resulted in the resident not receiving timely evaluation and care as directed by medical professionals.