F0684

D

Failure to Timely Arrange Ordered GI, Diagnostic, and ENT Services

Forestville, Maryland Survey Completed on 01-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow physician orders and arrange necessary gastrointestinal and diagnostic services for two residents. For one resident, the medical record showed a physician order dated 11/12/25 to schedule a gastrointestinal (GI) appointment for evaluation for gastrostomy tube (G-tube) removal, and a separate order dated 08/13/25 for a modified barium swallow study (MBSS). Interviews with the DON, a Unit Manager LPN, and the Unit Secretary established that the facility’s process required a nurse to relay appointment requests to the Unit Secretary, who would then schedule the appointment and return the details to the nurse for order updating and family notification. The Unit Secretary stated she never received any request for this resident’s MBSS or GI consult and was unaware these appointments needed to be scheduled until 01/07/26, at which point she began making calls to schedule them.

The deficiency also includes the facility’s failure to timely arrange a critical diagnostic test and specialty consultation for another resident with a neck mass. The resident’s provider assessed the resident on 10/30/25 and ordered a neck ultrasound, which was performed the same day and showed a left neck solid mass measuring 3 x 2 x 2 cm with a recommendation for a CT of the neck and chest. A CT neck order was placed on 10/30/25 at 11:11 PM, but the CT was not scheduled by the facility before the resident was transferred to the hospital on a later date at 6:30 AM per family request for neck pain management. During that hospital stay from 11/10/25 to 11/11/25, the resident received a CT scan of the neck, which revealed enlarged, partially necrotic, and enhancing left-sided lymph nodes suspicious for metastatic lymphadenopathy, and an ENT evaluation with possible biopsy was recommended. The hospital discharge summary instructed that an appointment with the ENT doctor be made or verified within one week.

Following the hospital discharge, the facility provider wrote an order on 11/12/25 for an ENT appointment and possible biopsy, but the ENT appointment was scheduled for 1/22/26. The appointment scheduler stated that this was the earliest available date and that, when a specific time window is required, she informs the doctor’s office so they can adjust the schedule; she confirmed she communicated the details of this case to the Unit Manager. The Unit Manager reported informing the resident’s family member of the earliest ENT appointment and stated the family member said they would look for an earlier appointment themselves, leading the Unit Manager to take no further action to adjust the schedule. However, a progress note documented only that the family was updated about the 1/22/26 appointment as the earliest available, and the family member later stated they were told they could seek an earlier appointment but did not indicate they would handle scheduling entirely on their own. The resident was later transferred back to the hospital for neck pain management, where a biopsy was performed and oropharyngeal cancer was diagnosed. The DON acknowledged that the CT scan and ENT consultation were not arranged in a timely manner.