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F0684
D

Failure to Notify Resident of Scheduled Medical Appointment Due to Lack of Process

Omaha, Nebraska Survey Completed on 11-18-2025

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 ensure that a process was in place to notify residents of scheduled medical appointments, resulting in a resident missing a critical cardiology appointment. Record review showed that the resident, who was cognitively intact and had significant medical diagnoses including carcinoma in situ of the cervix, anemia due to chemotherapy, and thrombocytopenia, was not informed of a scheduled cardiology appointment. The appointment was documented on the facility's appointment calendar and later marked as canceled after the resident did not attend. Progress notes indicated that the resident was unaware of the appointment and was eating breakfast when transportation arrived, leading to the missed appointment. The resident's hematology and oncology provider's office contacted the facility to stress the importance of the appointment due to an upcoming procedure. Interviews with facility staff revealed inconsistent understanding and communication regarding responsibility for notifying residents of appointments. The Director of Nursing stated that nurses document and communicate appointments to transportation, while the Medical Records Clerk and other staff provided differing accounts of who is responsible for notifying residents. The facility Administrator confirmed that there was no policy or procedure in place regarding appointment notifications. This lack of a clear process led to the resident not being informed and missing the scheduled medical appointment.

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