Failure to Ensure Resident Attended Infectious Disease Clinic Appointment
Penalty
Summary
The facility failed to ensure that a resident with HIV attended a scheduled infectious disease clinic appointment as ordered. The resident was discharged from the hospital with instructions for close follow-up at the infectious disease clinic and a prescription for Biktarvy, an antiretroviral medication. The resident, who had moderate cognitive impairment and a mental health disorder, was admitted to the facility with orders to continue Biktarvy and to manage chronic disease. The care plan included medication administration and monitoring for HIV complications. The Transportation Coordinator was responsible for arranging the resident's appointments and was aware that accompaniment was required per administrative policy. Attempts to contact the resident's guardian prior to the appointment were unsuccessful, and the appointment was cancelled and rescheduled. However, the Transportation Coordinator recorded the wrong date for the rescheduled appointment, resulting in the resident missing the actual clinic visit. The guardian was not notified of the correct appointment date and only learned of the cancellation and rescheduling after the fact. The resident was subsequently placed on a waiting list for a new appointment. Due to the missed appointment, the resident ran out of Biktarvy, as the pharmacy required a clinic visit before dispensing additional medication. Nursing staff and the nurse practitioner confirmed that the resident did not receive the medication for several days, and the infectious disease physician declined to refill the prescription without a recent clinic evaluation. The resident eventually resumed therapy after the facility pharmacy was able to obtain the medication, but the lapse in care occurred as a result of the missed appointment and communication failures among facility staff.