Failure to Schedule Required Post-Hospitalization Follow-Up Appointments
Penalty
Summary
A deficiency occurred when a resident who was readmitted to the facility after hospitalization for an upper gastrointestinal (GI) bleed and new onset atrial fibrillation with rapid ventricular response did not have required follow-up appointments scheduled with Cardiology and Gastrointestinal (GI) providers within one week post-discharge, as specified in the hospital discharge summary. The resident's diagnoses included gastrointestinal hemorrhage, anemia, atrial fibrillation, hypertension, anoxic brain damage, and seizure disorder. The hospital discharge summary and subsequent physician orders both indicated the need for these follow-up appointments, but there was no documentation that they were scheduled during the resident's stay. Interviews with facility staff revealed that the Unit Manager reviewed the hospital discharge summary but did not notice the instructions for follow-up appointments. The Nurse Practitioner wrote an order for the follow-up appointments and flagged it in the resident's chart, informing the assigned nurse, who later stated she was unaware of the orders. The Director of Nursing was also unaware of the need for these appointments and, upon review, confirmed that no appointments had been scheduled. The facility failed to ensure that the resident received services meeting professional standards of practice by not arranging the required follow-up care.