Failure to Provide Timely Urology Consultation as Ordered
Penalty
Summary
A deficiency occurred when a resident with diagnoses including end stage renal disease, obstructive and reflux uropathy, and urinary retention did not receive a urology consultation as ordered by the physician. The resident was admitted with an indwelling urinary catheter, and physician orders and progress notes repeatedly documented the need for a urology referral and evaluation. Despite these orders, the resident was not seen by a urologist during their stay, and the referral remained pending throughout their admission. Interviews with facility staff, including the DON and Nurse Supervisor, confirmed that the urology consult was ordered but not completed, with the Nurse Supervisor stating that referrals typically take a month or more to process. The resident ultimately was discharged against medical advice without having received the required urology evaluation. Facility policy indicated that the Director of Social Services, with assistance from nursing staff, was responsible for arranging such referrals, but this process was not completed in this case.