Failure to Communicate Specialist Recommendations to Physician
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards by not notifying the physician of recommendations following a specialist consultation for a resident with complex medical needs. The resident had diagnoses including spina bifida, hydrocephalus, neurogenic bladder, and neurogenic bowel. After a consultation with a spina bifida specialist, an after-visit summary was addressed to the Nursing Supervisor, which included a recommendation and order for a daily soap suds enema to begin on a specified date. Review of the resident's clinical record showed no progress note documenting the specialist consultation, no evidence that the primary care provider was informed of the new orders, and no entry of the enema order in the medication administration record. The physician's history and physical note did not reflect awareness of the consultation recommendations. During an interview, the DON confirmed that there was no documentation or communication with the primary care provider regarding the specialist's recommendations.