Failure to Provide Escort Resulting in Delayed Follow-Up EGD Appointment
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received ordered follow-up care with an outpatient gastroenterologist. A hospital After Visit Summary dated 11/13/25 documented that the resident underwent an esophagogastroduodenoscopy (EGD) which revealed a cratered ulcer in the middle third of the esophagus, with severe ulceration and peeling appearance that led to deferral of scope and dilatation. The hospital instructions directed a repeat EGD with an interventional gastroenterologist in four weeks. Facility progress notes dated 11/26/25 showed that the return EGD appointment was scheduled for 12/10/25 at 9:45 AM. The resident later reported on 1/14/26 that she had been having issues with swallowing and felt something in her neck, and stated that her gastroenterologist had been trying to determine the cause. She said she was supposed to have the repeat EGD on 12/10/25, but the appointment was cancelled by the facility due to no escort being available to accompany her, which she stated delayed her treatment and caused her to wait more than a month for the repeat EGD. On the same day, a registered nurse confirmed that, due to no available escort, the appointment had to be cancelled and rescheduled to 1/15/26, more than a month after the original date. The nurse and the receptionist both stated that, per instruction from the DON, the facility could only schedule one medical appointment per day with an escort because of staffing limitations.
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