Failure to Follow Physician Orders for Neurology and Psychiatric Consults
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards of practice by not following physician orders for specialty consultations. A resident was readmitted in October 2025 with diagnoses including encephalopathy and cardiac arrest. The clinical record showed a physician’s order dated 10/6/2025 for a neurology consult related to recent shock. Record review did not contain any evidence that this neurology consult was ever scheduled or completed after the order was written. The record also showed a physician’s order dated 10/16/2025 for a psychiatric and psychological health evaluation. A psychiatric evaluation and consultation form dated 10/28/2025 documented an assessment plan that included a follow-up in 30–45 days. Further record review did not show that the resident was seen for the ordered psychiatric follow-up. In interviews, the physician stated he expected the facility to schedule the neurology consultation and ensure psychiatric follow-up occurred, and the Director of Nursing Services was unable to provide evidence that either the neurology consultation had been scheduled or completed, or that the psychiatric follow-up visit had occurred.
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