Failure to Arrange Transportation and Pre-Appointment X-rays for Postoperative Follow-Up
Penalty
Summary
The facility failed to ensure that transportation was arranged for a resident's postoperative appointment as ordered by the physician. The resident, who had multiple complex diagnoses including cervical disc disorder, spinal stenosis, diabetes, and recent spinal surgery, was admitted with orders for a follow-up surgical appointment. The medical record and staff interviews confirmed that the resident missed the initial postoperative appointment because transportation was not set up by the facility. The appointment had to be rescheduled, and there was a lack of communication between the facility and the neurosurgery office regarding the resident's follow-up care. When the appointment was rescheduled, the resident arrived late and was not taken to radiology for X-rays prior to seeing the surgeon, as specified in the physician's order. The resident ultimately had the X-rays completed after the appointment instead. Interviews with staff revealed uncertainty about the transportation arrangements and the requirements for pre-appointment X-rays. The resident also confirmed that he was not informed about the need for radiology prior to the appointment and that transportation arrangements were not properly communicated or executed.