Failure to Arrange Physician-Ordered Prosthetic Clinic Referral
Penalty
Summary
The facility failed to follow a physician's order to arrange a referral to a prosthetic clinic for a resident with a pre-existing left above-the-knee amputation. The resident, who was cognitively intact and required supervision with daily activities, had a physician order documented for a prosthetic clinic referral. Nursing progress notes confirmed the order, but there was no documentation of an appointment being made. Multiple staff members, including the Social Service Director, Physical Therapy Assistant, and Transportation Director, were aware of the referral but did not ensure the appointment was scheduled. The Social Service Director informed the Interdisciplinary Team, but no follow-up occurred, and the Transportation Director was told not to make the appointment. The Nurse Practitioner who wrote the order expected it to be carried out, and the facility administrator confirmed that staff are expected to follow provider orders, although there was no formal policy in place. The lack of action resulted in the resident not receiving the necessary referral to the prosthetic clinic as ordered by the physician.