Failure to Ensure Residents Attend Scheduled Medical Appointments
Penalty
Summary
The facility failed to ensure that residents received the necessary care and services to attend outside medical appointments, as evidenced by two residents who missed or had to reschedule important medical visits due to errors in care coordination. For one resident with a history of cancer, malnutrition, depression, and falls, laboratory tests required for a chemotherapy appointment were not collected correctly. The lab initially drew the wrong tests, and when a STAT order was placed, the lab still failed to collect all required samples, resulting in the resident missing a scheduled chemotherapy session. Interviews confirmed that the appointment had to be cancelled and rescheduled due to these errors in lab collection. Another resident with chronic heart failure, kidney disease, and other conditions missed a scheduled bone density test because staff administered a calcium medication prior to the appointment, despite the absence of an order to hold the medication. As a result, the appointment had to be rescheduled. Both residents were cognitively intact and required varying levels of assistance with activities of daily living. The facility's policy states that residents have the right to access services outside the facility, but these incidents demonstrate a failure to coordinate care and services necessary for residents to attend their medical appointments as scheduled.