Failure to Schedule Ordered Neurology Consult for Resident with Tremors
Penalty
Summary
A deficiency occurred when a resident with diagnoses including adult failure to thrive and repeated falls was admitted and subsequently had a physician's order placed for a neurology consult due to increased tremors and trouble swallowing. Documentation showed that the order for the neurology consult was made, and the resident continued to experience symptoms such as upper extremity tremors and difficulty drinking. Despite these ongoing symptoms and the documented order, there was no evidence in the resident's record, progress notes, or the facility's transport calendar that a neurology consult was ever scheduled, attended, or declined by the resident. Interviews with facility staff, including an LPN and the DON, confirmed that the appointment was neither scheduled nor tracked, and the staff member responsible for appointments was unaware of the order. The resident also confirmed during an interview that they had not declined the appointment and continued to experience tremors, expressing the need for the consult. The facility was unable to provide any documentation that the neurology consult was arranged as ordered by the provider.