Failure to Provide Physician-Ordered Follow-Up Care and Documentation
Penalty
Summary
The facility failed to ensure that a resident received treatment and care as specified by hospital discharge orders and physician instructions, in accordance with professional standards and facility policies. The resident, who had a history of COPD with acute exacerbation and asthma, was discharged from the hospital with instructions for follow-up care, including a pulmonology consult within one month and a follow-up CT scan in July. Physician orders were present in the medical record for these follow-ups, and the facility's policy required timely requests for such services. Despite these orders, there was no documentation that the resident received the required pulmonology consult or the follow-up CT scan. The DON and other facility leadership confirmed that while attempts were made for the pulmonologist to see the resident, there was no record of the resident being unavailable or of the consult being completed. Similarly, there was no documentation explaining why the CT scan was not performed as ordered. The lack of documentation and follow-through on these physician-ordered services constituted a failure to provide care according to the resident's needs and professional standards. Interviews with facility staff, including the DON and the Regional VP of Clinical Services, revealed that they were unaware of the reasons for the missed appointments and acknowledged the absence of required documentation. The facility's own policies emphasized the importance of providing physician-ordered services and maintaining proper records, but these were not followed in this instance, resulting in the identified deficiency.