Failure to Notify Resident Representative of Rescheduled Medical Appointment
Penalty
Summary
The facility failed to notify the resident representative (RR) of a rescheduled medical appointment for one of two sampled residents, as required by their own policy. The RR reported that an appointment with a cardiovascular physician was changed by the provider, but the facility did not inform the RR, resulting in the RR being unable to attend the appointment. Review of the resident's progress notes showed documentation of the original and updated appointment dates, but there was no indication that the RR was notified of the change. The facility's policy on transporting residents to appointments specifies that the resident and/or responsible party will be notified of pending appointments and necessary transportation arrangements. During an interview, the Social Services Director confirmed that the RR should have been notified and acknowledged that the progress notes did not reflect such notification.
Plan Of Correction
A. What corrective action(s) will be accomplished for the patient(s) identified to have been affected by the deficient practice. It was documented in Resident 1's medical record that on 09/25/25, D.O.N. reviewed with resident's son (Michael) the findings and recommendations of the 9/24/25 vascular appointment. He did not have any issues. Resident 1 was discharged to an Independent Living Facility on 11/7/25 in stable condition and with no negative outcome. B. How other patients having the potential to be affected by the same deficient practice will be identified, and what corrective action will be taken. On 11/6/25, D.O.N. reviewed all scheduled appointments for the month of November. There are no issues on resident and/or responsible party notification of the appointment. C. What immediate measures and systemic changes will be put into place to ensure that the deficient practice does not recur. On 11/5/25 and 11/6/25, DON conducted an in-service to the licensed nurses and department managers to review the policy and procedure on "Resident's Appointments". Social Service staff will inform the resident, responsible party (if applicable), and nurses for any change in the appointment schedule. Social Service staff and Nursing will utilize the Scheduled Appointment Information form as a source of communication. D. How the facility plans to monitor its performance to ensure corrections are achieved and sustained. The plan of correction must be implemented, corrective action evaluated for its effectiveness, and it must be integrated into the quality assurance system. On 11/6/25, a QAPI Plan "Resident's Appointment Notification" was initiated by the IDT. Medical records will audit MD orders daily 5x/week to ensure that the resident and/or responsible party are notified of the appointments and documented in the record. D.O.N. and Administrator will be given a copy of the audit to ensure compliance. Findings of the audit will be discussed during the QAPI Committee meeting monthly x3 then quarterly and follow their recommendation for continued compliance. E. Dates when corrective action will be completed: November 11, 2025