Failure to Ensure Resident Attended Ordered Neurology Appointment and to Document Missed Visit
Penalty
Summary
The deficiency involves the facility’s failure to ensure a system was in place and implemented to enable a resident to attend an outside neurology/neurosurgery appointment as ordered and needed. The resident had a history of stroke with right hemi craniotomy, left-sided weakness, epilepsy, and severe cognitive impairment, and was dependent on staff for upper and lower body dressing. The resident’s preferred language required an interpreter. Physician progress notes from late 2024 and 2025 documented ongoing headaches, dizziness, left-sided weakness, and recommendations for follow-up with Neurology/Neurosurgery. However, these 2025 notes were not visible in the facility’s eMR until after surveyor inquiry due to a transcription/transfer issue between the physician’s own eMR and the facility’s system. The resident reported anticipating a neurology appointment the night before and being eager to attend due to persistent deep head pain, dizziness, cramping pain, and headache radiating from the base of the neck to the area of the prior craniotomy. On the morning of the scheduled appointment, the resident stated that no one came to get them dressed or ready and that they did not refuse the appointment. The MDS indicated the resident did not exhibit rejection-of-care behaviors and required total assistance for dressing, meaning staff preparation was necessary for the resident to attend the appointment. Staff interviews confirmed that the resident did not refuse the appointment and that there was no documentation of refusal. Interviews with the ADON, LPN/Charge Nurse, CNA, and DON revealed that appointment scheduling and communication processes were informal and inconsistently implemented. The unit clerk and LPN/Charge Nurse scheduled appointments and were supposed to document them in progress notes and on a white appointment board, but December appointment records were not kept. The CNA stated she was not informed to get the resident ready and did not recall the resident’s name on the appointment board. Review of the resident’s progress notes showed no entry that the appointment was missed, no documentation that the physician was notified of the missed appointment, and no evidence of a rescheduled neurology appointment prior to surveyor inquiry. The facility also could not provide a policy for scheduling resident appointments, despite having a documentation policy that required recording refusals and physician notifications, contributing to the failure to ensure the resident attended the ordered neurology follow-up.
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