Failure to Schedule Follow-Up Appointments and Labs per Hospital Discharge Orders
Penalty
Summary
The facility failed to ensure that follow-up appointments and laboratory work were completed according to the discharge instructions from the acute hospital for one resident. Upon admission, the resident had a history of chronic obstructive pulmonary disease (COPD), atherosclerotic heart disease, and had recently undergone surgical repair of an inguinal hernia. The hospital discharge summary specified the need for weekly CBC (complete blood count) tests and follow-up appointments with a surgeon, cardiologist, and pulmonologist. However, a review of the resident's medical record revealed that only one CBC was completed, and there was no documentation of any follow-up appointments being scheduled or conducted with the required specialists. Interviews with facility staff, including the Social Services Director, Licensed Vocational Nurse, RN supervisor, and MDS nurse, confirmed that the process for reviewing and implementing hospital discharge orders was not followed. The Social Services Director stated that nursing staff were responsible for scheduling appointments and notifying social services for transportation, but there was no record of such actions for this resident. The RN supervisor and MDS nurse both acknowledged that the necessary orders for ongoing labs and specialist appointments were missed during the admission process and were not entered into the system. The facility's policy required support in scheduling specialty healthcare appointments and arranging transportation, with documentation in the electronic medical record. Despite this policy, there was no evidence that the required follow-up care was arranged for the resident, resulting in a delay in care and treatment. The deficiency was identified during an unannounced complaint investigation, and the lack of follow-up had the potential to affect the resident's overall health condition.