Delay in Specialist Referrals for Contractures and Foot Drop
Penalty
Summary
A deficiency was identified when a resident with hemiplegia, hemiparesis, type 2 diabetes mellitus, reduced mobility, and major depressive disorder was not provided timely appointments with referred specialists for hand contractures and foot drop. The resident, who had intact cognition as indicated by a BIMS score of 15, repeatedly requested to see an orthopedic hand surgeon and a podiatrist for worsening contractures and drop foot. Despite multiple encounter notes and physician orders documenting the need for these referrals, there were significant delays in scheduling the appointments. The process for scheduling specialist appointments involved several steps: the in-house physician would order the referral, the floor nurse would enter and print the order for the physician's signature, and the signed order would then be routed to the Director of Transportation (DT) for scheduling. Interviews with staff revealed that the DT could only schedule appointments after receiving the signed order, and that delays could occur due to the need for provider acceptance, insurance verification, and document transmission. The DT, nurses, and DON described a workflow that required multiple handoffs and physical movement of paperwork, which contributed to the delay. Documentation showed that the resident's requests and the need for specialist evaluation were repeatedly noted from early February through late March, with orders for referrals being placed and re-affirmed multiple times. However, the actual appointment for the orthopedic hand surgeon was not scheduled until late April, with the appointment set for early May. The resident reported having to ask multiple times before the appointment was finally arranged, indicating that the facility did not reasonably accommodate her needs and preferences in a timely manner.