Failure to Coordinate Timely Specialist Referral and Wound Care Documentation
Penalty
Summary
The facility failed to ensure timely management of a resident's increased tremors as ordered by the physician. Despite repeated requests from the resident's representative and documentation in care conference notes and physician orders, the facility did not secure a neurology appointment for the resident experiencing worsening tremors related to Parkinson's disease. Referrals were only sent to the resident's previous neurologist, who no longer accepted the resident's insurance, and no attempts were made to contact other neurologists in the area. Communication between nursing staff and the transportation coordinator was limited to a spreadsheet, and there was no oversight to ensure the referral process was completed as ordered. The resident's care plan was not updated to reflect the need for neurology follow-up or the increased symptoms. Additionally, the facility did not monitor or document wound care for another resident who was on hospice and had a non-healing breast wound. The resident's representative reported that hospice was providing wound care, but there was no physician order or care plan in the facility's records addressing the wound or the facility's role in the care process. The facility's own policy required care planning and documentation for wound management, but this was not followed. The care plan was not integrated with the hospice plan of care, and facility staff did not have clear documentation of their responsibilities regarding the resident's wound care. These deficiencies were identified through observation, interviews with staff and resident representatives, and review of clinical records and facility policies. The lack of timely specialist referral and absence of wound care documentation and planning demonstrated a failure to provide care and services in accordance with physician orders, resident needs, and facility protocols.