Failure to Ensure Follow-Up and Scheduling of Medically Necessary Colonoscopy
Penalty
Summary
The facility failed to provide medically related social services necessary for a resident to achieve the highest practicable well-being by not ensuring a colonoscopy referral was properly followed up and scheduled. The resident, a female with a history of diabetes mellitus, cerebrovascular accident, transient ischemic attack, and non-Alzheimer's dementia, had a physician's order for a GI consult and colonoscopy. Documentation showed that the order was communicated to social services, and referral packets were faxed to the outside provider on multiple occasions. However, there was no evidence that an appointment was ever scheduled or that follow-up communication with the provider was documented. Interviews with the resident revealed she was informed months prior that a colonoscopy was recommended but was never given an appointment date or further information. The social worker and social worker assistant confirmed their roles in handling outside provider appointments, with the assistant responsible for sending referrals and following up. Despite sending the referral, the assistant had no documentation of any follow-up calls or actions taken after the initial fax, and the resident remained unaware of any scheduled appointment. Further interviews with nursing staff and the DON clarified that the process involved the NP writing the order, nursing communicating it to social services, and social services arranging the appointment and transportation. The DON stated that social services was expected to ensure appointments were scheduled and to follow up as needed. Despite these established responsibilities and policies, the lack of documented follow-up and communication resulted in the resident not receiving the ordered colonoscopy.