Failure to Follow Up on ENT Consultation Order
Penalty
Summary
The facility failed to follow up on a physician's order for an Ear, Nose, and Throat (ENT) consultation for a resident who was experiencing left ear pain and hearing loss. The resident, who had multiple diagnoses including end stage renal disease, anemia, hypertension, diabetes mellitus, and peripheral vascular disease, reported ongoing left ear pain and difficulty hearing for over a month. Despite a documented order for an ENT consultation and treatment for the resident's left ear pain, there was no evidence in the medical record that the consultation was scheduled or followed up by nursing staff, social services, or administration. Interviews with the resident, Social Services Director, and Director of Nursing confirmed that no follow-up calls or actions were taken to ensure the ENT consultation occurred after it was ordered. The Social Services Director acknowledged that no contact had been made with the ENT provider, and the Director of Nursing stated that the resident's needs were not being met due to the lack of follow-up. The facility's social worker job description indicated responsibilities for communication and intervention, but these were not fulfilled in this case.