Failure to Coordinate and Document Follow-Up Medical Appointments
Penalty
Summary
The facility failed to schedule and coordinate follow-up medical appointments as recommended for a resident who was admitted with multiple serious diagnoses, including Malignant Otitis Externa, Acute Osteomyelitis, Cholesteatoma of the External Ear, COPD, and Heart Failure. Upon admission, the hospital discharge summary recommended follow-up with an otolaryngologist within 3-7 days and a urologist within one week. Record review and staff interviews revealed that the staff member responsible for scheduling appointments did not recall making the necessary ear specialist appointment and stated that there was no documentation of any attempt to schedule these follow-ups. Further interviews with the DON confirmed that the scheduler handles appointments based on information from admissions, but there was no documentation of appointments or follow-up for the resident. Additionally, when the facility's policy for coordination of appointments was requested, it was not provided by the end of the survey. The lack of documentation and failure to coordinate the recommended follow-up appointments led to the deficiency.