Failure to Ensure Timely Specialist Referrals and Follow-Up Leads to Amputation
Penalty
Summary
The facility failed to ensure that a resident received care and services in accordance with professional standards of practice, specifically by not following up on critical medical appointments and referrals. The resident, who had a history of cardiovascular disease and was at risk for skin breakdown, was admitted with orders for a cardiology follow-up and later developed multiple wounds on the right foot. Despite physician orders and wound care recommendations for a vascular surgery referral due to deteriorating arterial wounds and poor blood flow, the facility did not ensure timely scheduling or follow-up of these appointments. Documentation shows that the cardiology appointment was missed and not rescheduled, and the vascular referral was delayed, with staff failing to document missed appointments or notify appropriate personnel. Multiple staff interviews revealed confusion and lack of clarity regarding responsibilities for entering, scheduling, and following up on physician orders and specialist referrals. The charge nurse, treatment nurse, and transportation driver each described breakdowns in communication and process, including a missed vascular appointment due to transportation issues and lack of documentation or rescheduling. The treatment nurse admitted to not following up on the wound doctor's orders and not documenting attempts to schedule the vascular appointment. The Director of Nursing was unaware of the missed appointments until after the resident's condition had significantly deteriorated. As a result of these failures, the resident's wounds worsened over several weeks, eventually developing gas gangrene and requiring an above-the-knee amputation. The resident was transferred to the hospital in an unkempt and malodorous state, with extensive gangrene to the right foot and lower leg. Staff interviews and record reviews confirmed that the lack of timely follow-up and documentation on critical medical appointments directly contributed to the resident's decline and subsequent amputation.