Failure to Ensure Timely Orthopedic Follow-Up After Fracture
Penalty
Summary
A resident with a history of hemiplegia, hemiparesis following a stroke, ventilator dependence, tracheostomy, and gastrostomy was admitted to the facility. The resident sustained a witnessed fall while a nursing assistant was changing their brief, resulting in a complaint of severe pain. Subsequent radiology confirmed a fracture of the distal tibia and fibula, and the resident was placed in a splint at the hospital with orders for an outpatient orthopedic follow-up within one week. Multiple progress notes documented the need for orthopedic follow-up, and nursing staff were instructed to arrange the appointment and send x-ray results to the orthopedic provider. Despite these orders and instructions, record review did not reveal evidence that the resident received the required orthopedic follow-up. Staff interviews indicated that an appointment was initially scheduled but was cancelled by the orthopedic office. The transport aide communicated the cancellation to the physician assistant, who believed the facility staff would reschedule, while the physician assistant stated he does not schedule appointments and expected facility staff to do so. This lack of follow-through resulted in the resident not receiving the ordered orthopedic evaluation.