Failure to Schedule Post-Surgical Follow-Up Appointment
Penalty
Summary
The facility failed to follow its policy and procedure regarding social services referrals by not scheduling a follow-up appointment with a surgeon for a resident who had recently undergone neck surgery for a C5-6 fracture and vertebral artery stenosis. Upon admission, the resident's history and physical report clearly indicated the need for a follow-up with the surgeon within two weeks. However, review of the clinical records and interviews with staff, including the LVN, DON, and Social Services Director, revealed that no such appointment was scheduled or documented. The information necessary to arrange the appointment, including the surgeon's name and hospital, was present in the resident's medical record, but was overlooked during the admission and subsequent reviews by social services. The resident reported having inquired about the follow-up appointment with social services but confirmed that no appointment had been made since admission. The care plan also included an intervention to follow up with the surgeon as indicated, but this was not carried out. The facility's policy required social services to coordinate medical referrals and document them in the resident's record, but this process was not followed, resulting in a delay in arranging necessary post-surgical care for the resident.