F0684

D

Failure to Implement Orthopedic Follow-Up and Document Assessments for Pain Management and Neurology Referral

Riverside, California Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide treatment and care according to physician orders and to conduct and document appropriate assessments for a resident with a left shoulder rotator cuff tear and neuropathy. The resident was admitted with diagnoses including a left shoulder rotator cuff tear and neuropathy and reported limited movement and pain in the left shoulder. Hospital records from an acute stay documented that orthopedics had recommended an outpatient follow-up after an MRI confirmed a rotator cuff tear, with discharge instructions specifying an orthopedic surgery follow-up in 2–3 weeks. A physician order dated October 10, 2025, directed an orthopedic follow-up in 2–3 weeks, but the order did not specify the reason for the consult, it was not incorporated into the care plan, and there was no documentation that an orthopedic appointment was scheduled within the ordered timeframe.

Record review and staff interviews confirmed that the orthopedic follow-up order was not implemented as written. The care plan addressing the resident’s musculoskeletal disorder and left shoulder rotator cuff tear did not include the physician’s order for an orthopedic consult. The RN acknowledged that there was no record of an appointment being scheduled within 2–3 weeks of the October 10 order and that the appointment was not scheduled until February 2026. The DON stated that staff were expected to call and set up such appointments within 72 hours of the order, that no one from the facility made the call, that the reason for the orthopedic consult was not documented in the order, and that the order was not added to the care plan. These omissions resulted in a delay in the resident being seen by an orthopedic physician for the rotator cuff tear.

The deficiency also includes failures related to pain management and specialty referral for the resident’s neuropathy. The resident had an admission order for gabapentin 100 mg three times daily for neuropathy, with an order to monitor pain every shift. Pain level documentation from late October to November 10, 2025, showed pain levels of 0 each shift. On November 10, 2025, the gabapentin dose was increased to 300 mg three times daily, but there was no documented nursing assessment prior to obtaining this order and no documented rationale for the dose increase in the progress notes. LVN 1, who obtained and carried out the order, stated that the resident reported the medication was not working and requested the physician be called, but LVN 1 did not perform or document a pain assessment before obtaining the increased dose, despite facility policy requiring pain assessment and management steps.

Additionally, on December 12, 2025, an order for a neurology referral was carried out for the same resident, who had neuropathy and had requested to be seen by a neurologist. There was no documented assessment indicating the need for the neurology referral and no documentation in the progress notes explaining why the referral was needed. The order for the neurology referral was also not added to the resident’s care plan. RN 1 stated that LVN 2 did not document the reason for the neurology consult, so the RN did not know what it was for. LVN 2 confirmed that he called the physician after the resident requested to see a neurologist but did not document the reason for the referral or add it to the care plan. These actions and omissions occurred despite facility policies requiring that referrals for medical services be based on physician evaluation and orders, coordinated with appropriate disciplines, and that comprehensive, person-centered care plans describe the services to be furnished and be revised as resident conditions and information change.