Failure to Provide Timely Gynecological Care for Resident with Abnormal Uterine Bleeding
Penalty
Summary
A deficiency occurred when the facility failed to provide timely gynecological care for a resident experiencing post-menopausal vaginal bleeding. The resident, who had a history of paraplegia, adjustment disorder, and hypertension, reported intermittent vaginal bleeding beginning in June 2024. Despite multiple progress notes documenting the resident's ongoing symptoms and requests for gynecological evaluation, there were significant delays in arranging appropriate specialist care. The initial assessment by the facility's nurse practitioner ruled out a urinary tract infection, but no further investigation was pursued for several months, even as the resident's symptoms persisted and sometimes worsened to heavy and painful bleeding. The resident's medical record showed repeated documentation of abnormal uterine bleeding, with recommendations for gynecological follow-up made by both the primary care provider and facility staff. However, logistical challenges, such as the need for stretcher transportation and difficulties in scheduling with a gynecologist who could accommodate the resident's bedbound status, led to multiple missed and rescheduled appointments. Interviews with staff revealed a lack of clarity regarding responsibility for scheduling these appointments, with the unit clerk unaware of the need for gynecological care until several months after the initial symptoms were reported. Social work staff indicated their role was limited to ancillary services, and the director of nursing was not familiar with the concern. Throughout this period, the resident continued to experience vaginal bleeding, which was observed by direct care staff and reported to nursing. The resident ultimately received a diagnosis of mixed high-grade endometrial carcinoma after a significant delay, following a surgical procedure performed under anesthesia. The facility's failure to ensure timely specialist evaluation and coordination of care, despite ongoing symptoms and repeated documentation of the need for follow-up, resulted in a delay in diagnosis and treatment of a serious medical condition.