Delay in Implementing Therapy Orders After Orthopedic Consultation
Penalty
Summary
A deficiency occurred when the facility failed to implement new medical orders in a timely manner following an orthopedic consultation for a resident with a fractured right humerus. The resident, who was admitted with a broken right arm and had the capacity to make decisions, reported not receiving any physical therapy (PT) for his right arm since admission. Medical records showed that after a follow-up orthopedic appointment, there was no documentation or evidence that the facility followed up with the orthopedic doctor for new orders or recommendations. The resident returned from the appointment without an After Visit Summary (AVS), and staff interviews confirmed that no follow-up or documentation was completed regarding the consultation or any new therapy orders until several days later. Further review revealed that the orthopedic doctor had ordered physical therapy for the resident's right arm, but this order was not received or implemented by the facility until seven days after the consultation. Staff, including the Occupational Therapist Assistant and Social Service Assistant, confirmed that the lack of documentation and follow-up led to a delay in therapy services. The Director of Nursing acknowledged that the expected process for following up on specialty appointments was not followed, resulting in a delay in care. The facility was unable to provide a policy or procedure for following up on new orders or recommendations from consulting doctors for residents who attended specialty appointments.