Failure to Follow Up on Vascular Diagnostic Orders
Penalty
Summary
The deficiency involves the facility’s failure to follow up on physician orders for diagnostic vascular studies for one resident. A vascular physician documented in a progress note that the resident was suspected to have both chronic venous insufficiency (CVI) and peripheral arterial disease (PAD) and ordered left leg arterial and venous duplex studies to be done at the facility. A subsequent nursing progress note the same day documented that the resident had returned from the vascular appointment with new orders from the vascular MD for a left leg arterial duplex and a left leg venous duplex, and that Social Services would follow up with appointments for these procedures. During surveyor review with the Assistant Director of Nursing, there was no documentation that the ordered arterial and venous duplex studies had been followed up on or completed, and the ADON acknowledged that the orders should have been entered on the physician orders and followed up. The Social Service Assistant stated that when a resident has an order for treatment outside the facility, the nurse is supposed to provide her a copy of the order so she can arrange the appointment and transportation, but she was not made aware of this resident’s orders until approximately two months after they were written. The facility’s policy on Medication and Treatment Orders required that verbal orders be recorded immediately in the resident’s chart with specific details, but the documentation and follow-up process for these ordered studies did not occur as required, resulting in a delay of treatment.
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