Failure to Arrange and Document Follow-Up Orthopedic Care
Penalty
Summary
The facility failed to provide medically-related social services to assist a resident in scheduling and attending follow-up appointments with an orthopedic surgeon after the resident sustained a fractured left femur during a transfer from bed to wheelchair. The resident reported wearing a knee immobilizer since the fall and stated that no follow-up appointment with an orthopedic surgeon was made. Documentation in the medical record indicated attempts to schedule an appointment were hindered by the resident's insurance not being accepted by local orthopedic offices. The facility staff noted efforts to contact the local county Health Systems and to schedule a primary care provider appointment to obtain a referral, but there was no documentation confirming that referrals were sent or that the resident was transported to scheduled appointments. Further, the facility was unable to provide documentation of communication with the resident's insurance provider, attempts to schedule appointments, or records confirming that the resident was seen by an orthopedic surgeon. The lack of documentation and follow-through on arranging necessary medical appointments and transportation resulted in the resident not receiving timely follow-up care after a significant injury.