Failure to Coordinate Ordered Vascular Studies and Follow-Up
Penalty
Summary
The facility failed to ensure that a resident with a history of diabetes mellitus, a foot ulcer, and a previous deep vein thrombosis (DVT) received ordered vascular studies and a follow-up appointment with a vascular surgeon. The resident was admitted with significant medical concerns, including chronic left arm swelling and pain following a DVT and removal of a peripherally inserted central catheter (PICC). The vascular surgeon ordered comprehensive venous and arterial ultrasounds of both the upper and lower extremities, with instructions for a follow-up appointment after the studies were completed. These orders were documented in the resident's medical record and care plan, which also included interventions to obtain and monitor diagnostic work as ordered. Despite these documented orders, the resident did not receive the required vascular studies or the follow-up appointment. The resident reported that he had been waiting several weeks for the studies and was unaware of the reason for the delay, noting that the staff member who previously coordinated his appointments had left. The current case manager confirmed that the need for these studies and follow-up was not communicated to her during the transition. Facility leadership acknowledged responsibility for coordinating such care and recognized the importance of the ordered tests. The facility's policy requires that residents receive care and services according to professional standards and care plans, but this was not followed in this instance.