Failure to Schedule Required ENT Follow-Up Appointment
Penalty
Summary
A deficiency occurred when the facility failed to schedule a follow-up appointment with an ENT physician for a resident who had been evaluated in the emergency room for a recurrent nosebleed. The resident, who was cognitively intact and had a diagnosis of heart failure, was discharged from the hospital with instructions to follow up with an ENT within five to seven days. Upon return to the facility, there was no documentation in the clinical record or appointment log indicating that the required ENT appointment had been scheduled. Interviews with facility staff revealed that the ADON was responsible for scheduling resident appointments and reviewing hospital records for necessary referrals. The ADON confirmed that, at the time of the resident's readmission, they did not identify the need for an ENT follow-up. The DON stated that there was no known monitoring process in place to ensure that appointments and referrals were scheduled, and could not explain why the ENT appointment was missed. The resident reported not being notified of or attending an ENT appointment during their stay.