Failure to Arrange and Complete Specialist Appointments per MD Orders
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with physician orders, the comprehensive care plan, and the resident's preferences. Specifically, the resident was not taken to her MD-referred pulmonary and dermatology appointments, despite orders dated 02/24/25 for referrals due to COPD and a rash. Interviews with the resident confirmed she had not attended either specialist appointment. Multiple staff interviews revealed confusion and lack of clarity regarding responsibility for scheduling and ensuring follow-through on specialist appointments. The DON acknowledged that the orders were not carried out and that there was no established system or designated person responsible for scheduling such appointments. Further interviews indicated that the failure to arrange the pulmonary appointment was due to an inability to find a pulmonologist and transportation issues. Staff, including the LPN, LVN, ADON, and Administrator, all recognized the importance of following through with MD orders for specialist care and acknowledged that the process had failed. The facility's policy required that orders for medications and treatments be consistent with safe and effective practices, but this was not followed in this instance.