Failure to Complete Neurology Consults and Determine Decision-Making Capacity
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and residents' needs for two of three sampled residents. For one resident with diagnoses including metabolic encephalopathy, cerebral infarction, and a lower spinal cord compression fracture, there were physician orders for a neurology consult within 2-4 weeks and a subsequent neuro consult for dementia. However, the resident was not seen by a neurologist as ordered. The resident's family member confirmed that the neurology appointment was missed, and facility staff interviews revealed that there was no documentation of appointment confirmation or follow-up in the resident's chart. The case manager was responsible for arranging and documenting such appointments, but this process was not completed, resulting in the missed consult. For another resident admitted with encephalopathy and a cognitive communication deficit, the medical record and assessments indicated severe cognitive impairment. The resident's history and physical noted that decision-making capacity should be deferred to psychiatry or neurology, but there was no clear documentation in the record regarding the resident's capacity to make decisions. Although the resident was seen by psychiatry, the visit summary did not address decision-making capacity, and the resident was not seen by neurology. Facility staff acknowledged that the determination of capacity was not completed or documented as required. Facility policies reviewed indicated that social services are responsible for ensuring medically related social services, including scheduling and transportation for appointments, and that informed consent procedures require documentation of a resident's capacity or surrogate decision maker. In both cases, the facility did not follow through with required consults and documentation, resulting in failures to meet physician orders and to determine and document decision-making capacity.