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F0684
D

Failure to Arrange Physician-Ordered Referrals

Los Gatos, California Survey Completed on 09-11-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to follow its own policies and procedures to ensure that physician orders for referrals were carried out for a resident. Specifically, a resident with chronic pain syndrome and rheumatoid arthritis had physician orders for a retinal screening and a rheumatology consult. These orders were documented in the clinical record, but there was no evidence that the referrals were arranged or that the resident was seen for these consultations. During interviews and record reviews, the social service assistant confirmed that she was responsible for arranging the consults and transportation but had missed the consult orders. The assistant director of nursing also confirmed that the physician orders for the consults were not carried out as required. The facility's policy stated that social services should coordinate and document physician-ordered referrals and arrange transportation, but this was not done for the resident in question.

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