Failure to Obtain Ordered Cardiology Consultation for Pacemaker Patient
Penalty
Summary
The facility failed to ensure that ordered cardiology services were provided for a male resident with multiple cardiac conditions, including atherosclerotic heart disease, chronic atrial fibrillation, congestive heart failure, and the presence of a pacemaker. The resident was admitted from another nursing home and later readmitted from an acute care hospital, with active physician orders that included Eliquis for atrial fibrillation, Lasix for edema and CHF, Toprol for hypertension, compression stockings, and a cardiology consultation. The resident’s MDS showed moderate cognitive impairment and dependence on staff for all ADLs, and he was receiving high‑risk anticoagulant, diuretic, and antiplatelet medications. During observation, the resident was seen in a reclining wheelchair with both lower legs visibly discolored red/dark red and swollen. Record review and staff interviews revealed that a physician’s order for a cardiology consultation had been in place since 9/18/25, but no cardiology provider notes or evidence of a completed consult were found in the medical record. The Interim DON stated she was unaware of the status of the consult and confirmed the resident, who had a pacemaker, should have had a cardiology consult shortly after the order was written. The Nurse Scheduler, who was responsible for arranging outside specialist appointments, acknowledged that the cardiology consult order had not been completed and stated it had “fell by the wayside.” She reported that she had assumed a prior vascular appointment meant a cardiology consult was not needed and later learned from the cardiology provider that the resident’s last cardiology visit had been more than a year earlier. The facility’s own assessment tool indicated it provided nursing services to manage residents with chronic cardiac conditions, yet the ordered cardiology consultation for this resident was not obtained for over three months.
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