Failure to Schedule Cardiology Follow-Up for Pacemaker Battery Replacement
Penalty
Summary
Facility staff failed to ensure that services were provided in accordance with professional standards of quality for one resident with multiple complex medical conditions, including hypertension, high cholesterol, dementia, depression, muscle weakness, cognitive and communication deficits, insomnia, and a pacemaker. The resident, who was severely cognitively impaired and unable to follow simple instructions or feed herself, returned from a recent emergency room visit with discharge instructions that included urgent follow-up with a cardiologist for pacemaker battery replacement and an outpatient ultrasound for thyroid nodules. Upon review, it was found that while the facility staff followed up on the thyroid nodule recommendation, they failed to schedule the required cardiology appointment for pacemaker battery replacement as ordered by the physician. Both the administrative staff responsible for transportation and the LPN unit manager confirmed that no cardiology appointment had been scheduled for the resident, and the need for follow-up was missed upon the resident's return from the ER. This omission was only identified during the survey, and the lack of scheduled follow-up was confirmed through interviews and documentation review.