Failure to Schedule and Follow Up on Ordered Medical Appointments
Penalty
Summary
The facility failed to ensure that two residents received necessary care and services related to follow-up medical appointments, as ordered by their providers. One resident, admitted with diagnoses including spinal stenosis and diabetes, had an order for an abdominal ultrasound to rule out a hernia, which was completed and confirmed a small right inguinal hernia. The nurse practitioner subsequently ordered a GI surgical consult, but there was no evidence in the records that this consult was scheduled by the facility. The resident reported having to schedule the GI appointment independently after repeated requests to staff, and attended the appointment, providing paperwork to the nurse. However, staff interviews revealed a lack of awareness about the appointment and its outcome, and the new nurse practitioner was unaware of the need for cardiac clearance for surgery following the GI consult. Another resident, admitted with diabetes and chronic obstructive pulmonary disease, had orders for lab work, a CT scan, MRI, and a neurology referral. While some lab results were faxed as part of the neurology referral process, there was no evidence that the CT or MRI were scheduled, nor that the neurology appointment was arranged by the facility. The resident and their spouse ultimately scheduled the neurology appointment themselves after waiting for months without information from staff. The transport aide indicated that incomplete referral information from nursing staff prevented her from scheduling the neurology appointment, and there was no documentation of follow-up for the required imaging or consults. Interviews with both residents' physicians confirmed that it was their expectation that the facility would have scheduled and followed up on the ordered consults. The Director of Nursing Services and the Administrator were unable to provide evidence that the facility had followed up or scheduled the necessary appointments as ordered by the providers. The records lacked documentation of the appointments and outcomes, indicating a failure in the facility's processes for ensuring residents receive timely and appropriate follow-up care.