Failure to Schedule and Document Urgent Urology Appointment
Penalty
Summary
Facility staff failed to follow professional standards and the facility's own policy regarding the transcription and execution of physician orders for a resident with a diagnosis of prostate cancer. After a urologist contacted the facility and requested an urgent appointment for the resident, staff documented the need for an appointment and prepared transportation paperwork, but did not actually schedule the appointment. When a Certified Nurse Aide escorted the resident to the urologist's office, they were turned away because no appointment had been made. The CNA reported the incident to the charge nurse, but there was no documentation of any follow-up or rescheduling of the appointment in the resident's medical record. Interviews with staff revealed that the responsibility for making and documenting the appointment was unclear, with some staff believing the Director of Nursing and Administrator would handle the situation. The resident, who had moderate cognitive impairment and a history of prostate surgery, was unaware of any scheduled appointment and did not recall attending one. The facility's policy required that physician orders be transcribed, appointments scheduled, and all actions documented in the medical record, but these steps were not completed, resulting in a delay in the resident receiving necessary follow-up care.