Failure to Ensure Timely Orthopedic Follow-Up After Resident Fracture
Penalty
Summary
Resident #4, who had diagnoses including dementia, multiple fractures, nontraumatic intracerebral hemorrhage, and repeated falls, experienced an unwitnessed fall resulting in pelvic and iliac crest fractures. Following hospitalization, the discharge instructions specified that the resident should remain non-weight bearing on the right lower extremity and have a follow-up appointment with an orthopedic surgeon within 2-4 weeks. The facility's policy required assistance in scheduling outside appointments per provider recommendations. However, there was no documented evidence that the required orthopedic follow-up appointment was scheduled or completed as directed by the hospital discharge instructions. Interviews with facility staff revealed that discussions about the follow-up appointment and transportation occurred, but no documentation was provided to confirm these discussions or any follow-up actions. The Director of Therapy mentioned attempting to arrange a telehealth consultation with an orthopedic surgeon but could not provide documentation or a date for this action. The Director of Nursing confirmed that the unit manager and unit clerk were responsible for reviewing discharge paperwork and scheduling follow-up appointments, but no records of an orthopedic consult or appointment were available. The lack of documentation and follow-through resulted in the resident not receiving care in accordance with professional standards and the hospital's discharge instructions.