Failure to Ensure Resident Attendance at Medical Appointments and Documentation of Follow-Up Care
Penalty
Summary
The facility failed to ensure that a resident with diagnoses including colon cancer, cognitive communication deficit, and epilepsy attended multiple scheduled physician appointments outside the facility. The resident, who had severely impaired cognition and required maximal to partial assistance with daily activities, missed several important medical appointments for colorectal surgery surveillance and neurology follow-up. The missed appointments were due to issues such as lack of available escorts, transportation staff declining responsibility, and facility staff being unaware of scheduled appointments. There was also a failure to document nursing progress notes following outside medical visits. Specifically, after the resident attended an appointment, the charge nurse did not document the resident's return, update new orders, or follow up in the resident's chart. The charge nurse acknowledged not ensuring a proper handoff to the next shift, which would have facilitated documentation and follow-up on new orders and appointments. The facility's process, as described by staff, included communication of appointments, documentation of departures and returns, and handling of new orders, but these steps were not consistently followed. Interviews with facility staff revealed gaps in communication and documentation practices. The social services worker, registered nurse supervisor, charge nurse, care coordinator, and director of nursing all described processes that were not effectively implemented, resulting in missed appointments and lack of documentation. The facility's policy required assistance with scheduling, transportation, and documentation of appointments and new orders, but these procedures were not adhered to in this case.