Failure to Involve Medical Director in Securing Surgical Consult
Penalty
Summary
Facility staff failed to involve the Medical Director when they encountered ongoing difficulties in scheduling a surgical consult for a resident with a rectal prolapse. The resident, who had diagnoses including rectal prolapse, Barrett's Esophagus, GERD, and dementia, was assessed as having intact or borderline cognition. After a physician assistant identified a rectal prolapse and attempted but was unable to reduce it, a referral to colorectal surgery was ordered. Despite the referral being sent and multiple documented follow-up attempts by the facility scheduler over several months, no appointment was secured for the resident. Throughout this period, staff continued to document the resident's condition and made repeated calls to the surgical clinic, but were consistently informed that no appointment had been scheduled. The scheduler also attempted to contact another clinic, which did not perform the required surgery. At no point during these delays did staff seek the Medical Director's assistance, and the Medical Director later confirmed he had not been contacted regarding the issue. The deficiency centers on the staff's failure to utilize the Medical Director's role in coordinating medical care when standard processes were unsuccessful.