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F0684
D

Missed Medical Appointment Results in Delay of Care

Tulsa, Oklahoma Survey Completed on 11-21-2025

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

A deficiency occurred when the facility failed to ensure that a resident attended a required medical appointment following hospital discharge. The resident, who had a history of amputation, peripheral vascular disease, and end stage renal disease, was discharged from the hospital with instructions to follow up with podiatry two weeks after surgery. The resident was moderately impaired for daily decision making, as indicated by a BIMS score of 12. Documentation showed that the resident preferred to have the surgeon remove sutures, and an appointment was scheduled for this purpose. However, the appointment was missed because staff did not see it on the dashboard, resulting in the resident not being transported to the appointment as planned. The missed appointment led to a delay in therapy, as the resident's representative stated that the appointment would have provided necessary orders for weight bearing as tolerated, which could have allowed the resident to receive more therapy before discharge. The social services director and DON confirmed that the appointment was scheduled and transportation arranged, but the oversight in not noticing the appointment on the dashboard caused it to be missed. Although the physician was notified and provided instructions to remove the sutures and reschedule the appointment, the resident was discharged before the rescheduled appointment could occur.

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