Failure to Follow Neurosurgeon's Discharge Instructions and Exclude Resident/Family from Virtual Follow-Up
Penalty
Summary
The facility failed to follow a neurosurgeon's discharge instructions for a resident who had recently undergone major back surgery and had diagnoses including obstructive sleep apnea and a T11-T12 vertebral fracture. After the resident experienced an unwitnessed fall in his room, the discharge instructions specified that the resident should be sent to the emergency department or 911 should be called. Instead, the facility delayed action, with an x-ray not being performed until the following day despite the family's request for immediate imaging due to the recent surgery. Documentation shows that the order for the x-ray was not placed until several hours after the fall, and the discharge instructions were not followed as written. Additionally, the facility did not ensure that the resident and his family were included in a scheduled virtual follow-up appointment with the neurosurgeon. Although the family and resident wished to participate and had questions regarding the fall and the absence of a required back brace, the LPN took the call from the neurosurgeon's office alone, without including the resident or family as requested. The LPN also indicated a lack of familiarity with the technology required for virtual visits, and the facility did not have a policy in place for conducting such appointments.