Failure to Notify Physician of Inability to Obtain Ophthalmology Consult After Resident Injury
Penalty
Summary
Facility staff failed to notify the physician when they were unable to obtain an ophthalmology consult for a resident who had sustained a significant bruise and a small gash to the left peri-orbital region. The resident, who had dementia and was unable to follow instructions, was found with facial bruising and initially gave conflicting accounts of how the injury occurred. Medical documentation indicated that an ophthalmology consultation was ordered to further evaluate the injury, but there was no evidence in the medical record that the consult was ever completed. Despite the provider's expectation that they would be notified if an ophthalmology appointment could not be secured promptly, there was no documentation that the nurse practitioner was informed of the failure to obtain the consult. The Director of Nursing confirmed the absence of such documentation. This lack of communication and follow-through on the consult order constituted the deficiency identified during the complaint survey.