Failure to Provide Physician-Ordered Specialist Consultations
Penalty
Summary
The facility failed to ensure that a resident received physician-ordered consultations with a lymphedema specialist and a nephrologist. The resident, who had diagnoses including lymphedema, type 2 diabetes mellitus, stage 2 chronic kidney disease, and hyponatremia, had documented physician orders for follow-up with a nephrologist and an outpatient lymphedema clinic. Despite these orders, there was no evidence in the medical record that the resident received either consultation. Staff interviews revealed that attempts were made to schedule the lymphedema appointment, but the process was not completed due to referral requirements and the inability to locate a specialist within the facility's transportation radius. The nephrology appointment was not scheduled because the responsible staff were not informed of the need for the follow-up. The resident was observed with significant swelling and skin issues related to lymphedema and expressed that she had not received the specialist appointments she expected upon admission. Staff involved in scheduling and transportation confirmed communication gaps and incomplete follow-through on the physician's orders. The facility's policies required nursing staff to follow physician orders and assist with transportation for outside services, but these procedures were not effectively implemented for this resident, resulting in missed consultations.