Failure to Obtain Timely Outside Professional Consults
Penalty
Summary
Facility staff failed to obtain timely outside professional services for two residents as required. For one resident with chronic kidney disease stage IV, a physician ordered a nephrology consult upon admission in December 2024. However, as of early April 2025, the resident had not been seen by a nephrologist nor had an appointment scheduled. This was confirmed by both the Director of Nursing and Assistant Director of Nursing, who acknowledged that staff did not schedule the necessary consult. In a separate incident, another resident with dementia developed significant bruising and swelling around the left eye, with a small gash to the eyebrow. The nurse practitioner requested an ophthalmology consult to evaluate the injury, but review of the medical record showed that no such consult was obtained following the incident. Although the resident had a preplanned retinal specialist appointment a month after the injury, this was unrelated to the acute event. The DON agreed that the resident could have been sent to an eye clinic or emergency room for timely evaluation, but this did not occur.