Failure to Document and Schedule Physician-Ordered Follow-Up Consultations
Penalty
Summary
Surveyors identified that the facility failed to ensure physicians reviewed residents' total programs of care and documented progress notes and orders at each required visit for two out of three residents reviewed for follow-up consultation visits. Specifically, one resident admitted after a right hip fracture had an orthopedic consultation recommending a follow-up visit and x-ray in six weeks. However, there was no documented evidence that a physician's order for the follow-up was entered, nor was the appointment scheduled before the resident was discharged home. The resident's discharge instructions included a recommendation to follow up with orthopedics post-discharge, but the required in-facility follow-up was not arranged or documented. Another resident, admitted after a left hip fracture, was also scheduled for an orthopedic follow-up consultation. The consultation report specified a follow-up appointment, but there was no documented physician's order for this visit. The resident was discharged without having the follow-up orthopedic appointment completed. Review of the medical record and staff interviews confirmed the absence of documentation regarding the follow-up consultation, and it was noted that the resident would sometimes cancel appointments, but this was not consistently documented in the medical record. Interviews with facility staff, including the unit clerk, LPN, nurse practitioner, and medical director, revealed inconsistent practices regarding the scheduling and documentation of follow-up consultations. The nurse practitioner stated that recommendations from consultations were verbally communicated to nursing staff, but orders were not entered into the electronic medical record. The medical director acknowledged that orders and progress notes for consultations should be documented and that the current process allowed for lapses in scheduling and documentation, leading to missed appointments.