Failure to Schedule Neurology Consult per Physician Order
Penalty
Summary
The facility failed to follow physician orders to obtain a neurology consult for a resident who required a second opinion for spine consultation at a tertiary care center. Despite a physician's order dated June 18, 2025, there was no evidence that an appointment had been scheduled for the resident. The resident, who was admitted with multiple diagnoses including mononeuropathy of the left lower limb, PVD, hypertension, heart disease, and other significant conditions, reported ongoing leg weakness and expressed frustration about the delay, stating that staff indicated it could be several more months before an appointment could be arranged. The resident was cognitively intact and dependent on staff for most activities of daily living. During the investigation, the staff member responsible for scheduling appointments was unable to locate any documentation or confirmation of a scheduled neurology appointment for the resident, either in the facility's appointment calendar or among her personal and office papers. The facility's policy requires that upon receiving a physician's order for an outside appointment, the nurse must notify the staff member coordinating transport and ensure the appointment is scheduled and tracked. However, there was no system in place to reliably track or confirm appointments, resulting in the resident's continued wait for necessary medical evaluation.