Failure to Coordinate Diagnostic, Specialty, and Wound Care Services
Penalty
Summary
The facility failed to provide timely coordination of care for diagnostic imaging, laboratory services, and specialty consultations for two residents. One resident with a history of volvulus and abdominal distension experienced a delay of one week in scheduling a recommended CT scan after a GI specialist noted a distended abdomen and advised imaging to rule out obstruction. Both the resident and her family reported ongoing abdominal enlargement without explanation, and the unit manager could not account for the delay in following up on the specialist's recommendation. Another resident with malignant brain cancer, dysphagia, and significant weight loss had multiple physician orders for fecal occult blood testing and a GI consult over a two-month period. Despite repeated orders, there was no documentation of completed stool tests or a GI consult, and staff were unable to locate test results or confirm that the consult had occurred. The DON and APRN confirmed the absence of results and consult documentation, and the GI specialist did not recall providing a consultation for the resident. Additionally, the facility failed to obtain physician orders for wound care and did not complete weekly wound measurements for a resident with multiple abrasions. Documentation showed gaps of up to two weeks without wound measurements for abrasions on the right gluteal area, left ischial tuberosity, and penis. There were no physician orders for the right gluteal wound, and the prescribed treatment for the left ischial tuberosity was not followed. Nursing staff could not provide details about the wound care products used, and the DONs confirmed that weekly wound measurements were not consistently performed, with no documented refusals from the resident.