Failure to Schedule and Document Timely Outside Professional Services
Penalty
Summary
The facility failed to ensure timely scheduling and documentation of outside professional services for two residents. One resident, who had a tracheostomy and a history of repeated falls and GERD, was scheduled for a tracheostomy evaluation. Although the resident attended the initial appointment, the facility did not document awareness of the follow-up appointment that was scheduled by the otolaryngology provider. This lack of documentation indicated a failure to coordinate and track necessary outside services as ordered by the physician. Another resident, admitted with diagnoses including respiratory failure, immunodeficiency, and kidney transplant rejection, was discharged from the hospital with instructions to follow up with the transplant surgery office within three weeks. The facility did not schedule this follow-up appointment, and there was no evidence in the clinical record or physician orders that the appointment was made. Staff interviews confirmed that the required outside appointments were not scheduled in a timely manner for both residents.