Unauthorized Nephrology Consultations Without Orders or Contract Oversight
Summary
Facility administration allowed a nephrology nurse practitioner (NP #13) to provide consultation services to residents without an established contract in place and without physician orders authorizing these consultations, contrary to facility policy. For Resident #16, a nephrology consult was completed on 1/13/26 and not uploaded until 1/15/26, and there was no physician order for this resident to be seen by a nephrologist or consultant. Within that consult, NP #13 documented a medication error on the resident’s medication administration record but did not notify facility staff; the error was instead brought to the DON’s attention by the survey team on 1/21/26, eight days after NP #13 identified it. The facility’s policy on Provision of Physician Ordered Services, revised 2/18/25, states that no diagnostic tests or consultation requests will be performed without specific orders from a physician, PA, NP, or CNS in accordance with state law. Further record review of four additional randomly selected residents showed that all had been seen by the same nephrology NP consultant beginning around 11/9/25, with consultation notes uploaded days after the visits and no corresponding physician orders for nephrology consultations. NP #13 was reportedly seeing every new admission based on lists provided by unit managers when she arrived. The facility medical director stated that the process for nephrology consultation should involve residents with a diagnosed need and an order from their attending physician, and acknowledged that the contract for this consultant was not signed until 1/27/26, despite her seeing residents since at least November 2025. He also stated that he was not the resource following up on NP #13’s consultations and that this should be an actual nephrologist, and there was no nephrologist signing off on NP #13’s consultations.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with low back pain, anxiety, and a hx of TIA had a physician-ordered neurosurgery follow-up that was scheduled but not completed. The DON stated there was no documentation that the resident went out for the appt, Social Services said transportation was not arranged in time, and the missed visit was not rescheduled before the resident was discharged. The facility policy required staff to assist residents with scheduling and attending ordered follow-up appts.
Failure to obtain ordered infectious disease and urology consults: A resident with dementia, stroke-related weakness, immunodeficiency, chronic pain, and genital HSV had severe cognitive impairment and complained of groin pain while moaning with movement. An ID appt was cancelled by facility staff because no CNA was available to accompany the resident, and a urology order for penile cellulitis and chronic HSV/condyloma remained without consult documentation or explanation for why it had not been discontinued.
A resident with chronic pain, stage 4 pressure ulcers, paraplegia, and other serious diagnoses said his pain meds were decreased after admission and his requested pain clinic appointment was not scheduled for months, despite physician notes referring him to pain clinic. In addition, an RN left the med cart computer unlocked with resident records and the nurse report sheet visible to passersby, and the DON confirmed resident privacy should have been protected.
Failure to Complete Outside Specialty Referrals: Three cognitively intact residents had ordered specialty follow-ups that were not completed. One resident missed an ortho appointment and it was not rescheduled, another had a urology consult ordered for suprapubic catheter evaluation but the visit was never booked, and a third had an active neurology referral for Botox related to bilateral contractures that was not followed through. Staff interviews showed the orders were known or transcribed, but the appointments/referrals were not carried out.
A resident with impaired kidney function and stage four kidney failure had a physician-ordered nephrology consult, but staff did not document timely attempts to schedule the appointment before discharge. Nursing notes showed family contact about the consult and scheduling concerns, while a family member reported the visit still had not been arranged. An LPN said another staff member had been responsible for appointments, and the DON stated appointment setup, transportation needs, and family contact should be documented.
A resident with vertigo and multiple comorbidities, including Type 2 DM with neuropathy, heart failure, and CKD stage 3A, missed a scheduled ENT appointment when transportation arrived but the resident had not been informed of the appointment and was not prepared to go. The resident reported being told the appointment would be rescheduled, but this did not occur. An RN confirmed the appointment had to be rescheduled and that Medical Records staff handle such scheduling, while the CNA/Medical Records staff stated she was not aware the appointment needed rescheduling and later did not complete the task due to lack of time. The DON stated that appointments are expected to be followed up on timely, and the facility’s Transportation Services policy requires coordination with the Medical Records designee and timely rescheduling, which did not occur in this instance.
Missed Neurosurgery Follow-Up Appointment
Penalty
Summary
The facility failed to follow a physician-ordered follow-up neurosurgery appointment for a resident admitted with low back pain, anxiety disorder, and a history of TIA. The resident's admission record, MDS, discharge summary, physician orders, and progress notes showed that the resident had severe cognitive impairment and required assistance with multiple activities of daily living. The discharge summary indicated follow-up with a neurosurgery specialist, and subsequent physician notes and orders continued to document the need for neurosurgery follow-up for low back pain with small L3-4 infarction. The facility scheduled a neurosurgery appointment for 12/22/2025, and the transportation requisition was given to Social Service staff. During interviews, the SSD stated there was only one neurosurgery appointment and could not locate documentation showing whether it occurred. The DON stated the appointment was made, but there was no documentation that the resident went out to a clinic for it. SSA 2 stated Social Services arranged transportation after appointments were made, but there was not enough time to arrange transportation for the appointment, and the transportation request form was returned to CMA 1. Further interviews showed that transportation was never arranged by Social Services, and the follow-up neurosurgery appointment was not completed. The DON stated the resident was discharged from the facility on 2/24/2026, and the appointment was not rescheduled. CMA 1 stated the appointment was rearranged on 12/18/2025 and the transportation requisition was given to SSA 1 the same day, but CMA 1 believed the appointment had been completed and was not informed by nursing staff or Social Services that it had been missed. The facility policy stated staff would assist residents in scheduling and attending follow-up appointments as ordered by the physician.
Failure to Obtain Ordered Infectious Disease and Urology Consults
Penalty
Summary
The facility failed to follow a physician’s order to obtain timely infectious disease and urology consults for a resident with multiple complex diagnoses, including dementia with behavioral disturbance, stroke with right-sided weakness, immunodeficiency disease, chronic pain syndrome, papillomavirus, expressive aphasia, and genital herpes. During an interview, the resident complained of groin pain and moaned with movement while seated, and a family member stated that the resident was in constant pain and that the medications being provided were not working. The resident’s BIMS score was 3/15, indicating severe cognitive impairment. A physician ordered an infectious disease evaluation, and an appointment was scheduled, but the facility cancelled it the morning of the visit because staff said there was no available nursing aide to accompany the resident. The outside office reported that the facility cancelled the appointment because it could not send a CNA and stated the resident could not go without one. The record also contained a physician order to schedule a urology consult for penile cellulitis and chronic HSV infection with condyloma acuminata, but the scheduler could not produce urology consult notes and could not explain why the order had not been discontinued by the attending physician.
Delayed Pain Clinic Referral and Unsecured Resident Records
Penalty
Summary
A resident with stage 4 pressure ulcers, paraplegia, osteomyelitis, spastic hemiplegia, and injury of the root of the cervical spine reported ongoing pain after admission and said the house physician decreased his pain medication. He stated he requested a pain clinic appointment because of the decreased pain medication and asked for a telehealth appointment, but it was never scheduled until much later, despite a physician note documenting that he wanted more opioids and would be referred to a pain clinic. The record also showed follow-up notes about chronic pain and referrals, but the facility had no documentation that the pain clinic appointment was scheduled after admission, and the DON acknowledged there was no documentation that it had been scheduled. During observation of the medication cart, the computer was unlocked and open to resident records, and the cart contained the nurse's resident roster and report sheet with medical information visible to passersby. RN 1 was observed leaving the area and confirmed the computer had been left open and unattended. The DON stated that when staff walk away from the medication cart, the MAR and nurse report sheet should not be visible when staff are not around, and that staff should always protect resident privacy.
Failure to Complete Outside Specialty Referrals
Penalty
Summary
The facility failed to ensure outside professional services were obtained for three residents when referrals and appointments were not completed or followed through. Resident #1, who was admitted with spinal stenosis, low back pain, left leg pain, and difficulty walking, had a scheduled orthopedic appointment that was missed and was not rescheduled. The resident was cognitively intact and told surveyors that the appointment had been missed and no other appointment had been scheduled. Records showed the orthopedic appointment had been entered into the facility dashboard with a request to book transportation, but the appointment was not completed. Resident #33, who was admitted with heart failure, benign prostatic hyperplasia, diabetes, depression, and chronic pain, was cognitively intact and required an indwelling catheter. The resident stated he/she was supposed to see someone about getting a different type of catheter but did not know why the visit had not occurred. The physician order dated 3/14/26 directed a urology consult for suprapubic catheter need, and the Nurse Supervisor transcribed the order, but the urology appointment had not been booked. The DON stated she was not aware of the referral and nursing should have booked the appointment. Resident #2, who was admitted with peripheral vascular disease, dysphagia, and muscle weakness, was cognitively intact and had functional limitations in range of motion in both upper extremities. The resident reported contracted fingers that limited mobility and said he/she had previously worked with OT without improvement. Active physician orders directed neurology referral for Botox related to bilateral contractures, but staff could not locate evidence that the resident had been seen by neurology. The NP stated she was not aware of the active order and would have expected staff to place the referral, and the DON stated monthly order review should have identified the need for the neurology referral.
Failure to Arrange Nephrology Appointment
Penalty
Summary
Facility staff failed to ensure arrangements were made for outside nephrology services for one resident with impaired kidney function. The resident’s annual MDS dated 01/01/26 identified the resident as cognitively intact, always incontinent of bladder, and having a diagnosis of impaired kidney function. The physician ordered a nephrology consult on 02/08/26, and the medical record also showed physician progress notes and an email requesting that staff schedule a nephrology appointment. The facility admission agreement stated that if a resident chose a physician without facility privileges, the resident would travel at their own expense, but it did not provide direction for assistance with transportation or appointment setup. Nursing notes documented that staff left a voicemail for the family about the nephrology consult, spoke with the family about wanting an update on the appointment date and time, and later spoke with the family again when the family said the appointment needed to be scheduled 30 days out because of work requests. The record did not show documentation that staff attempted to schedule the nephrology appointment from the original order until the resident discharged from the facility on 03/30/26. During interview, a family member stated the nephrology appointment had been ordered in February and still had not been set up, and said the resident’s blood work showed stage four kidney failure. An LPN stated another staff member had been responsible for scheduling appointments and was no longer employed, and the DON stated staff would be expected to set up appointments within a day or two of receiving the order and document attempts, appointment dates, transportation needs, and family contact.
Failure to Coordinate and Reschedule ENT Appointment for Resident with Vertigo
Penalty
Summary
The deficiency involves the facility’s failure to coordinate and follow through with an outside Ear, Nose and Throat (ENT) medical appointment for one resident. On 04/08/2026, the resident was observed in bed in a nightgown and reported having vertigo and being scheduled to see an ENT specialist. He stated that on the day transportation arrived for the appointment, he was not ready because no one at the facility had informed him of the appointment, and that this occurred about a month prior. He further stated the facility told him the appointment would be rescheduled, but it never occurred. Record review showed the resident was originally admitted on 10/10/2023 and readmitted on 02/26/2026 with diagnoses including Type 2 DM with diabetic neuropathy, heart failure (unspecified), and CKD stage 3A. An order summary dated 04/08/2026 showed an ENT appointment scheduled for 02/11/2026 at 11:00. In an interview, an RN confirmed the resident had an ENT appointment on 02/11/2026 for vertigo that had to be rescheduled and stated that Medical Records staff are responsible for scheduling appointments, but she did not know if the appointment was ever rescheduled. The CNA/Medical Records staff member reported that the NP had informed her that the resident wanted to see the ENT, but she was not made aware that the appointment needed to be rescheduled after it was missed. She stated that on a Monday shortly before the survey, the NP asked if she had rescheduled the ENT appointment, and she told the NP she would get to it but did not reschedule it because she did not have time. The DON stated his expectation that appointments should be followed up on timely. The facility’s Transportation Services policy, dated 02/2025, states that the facility will arrange transportation services as needed to ensure each resident receives a complete continuum of service consistent with the plan of care and outlines procedures for notifying the Medical Records designee and rescheduling appointments when necessary, which were not followed in this case.
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