Failure to Schedule and Maintain Post-Op Orthopedic Follow-Up Appointment
Penalty
Summary
The facility failed to ensure services were provided according to professional standards of practice when staff did not arrange a scheduled post-operative orthopedic follow-up appointment for one resident. The resident was admitted with diagnoses including orthopedic aftercare and dementia, and the local hospital’s After Visit Summary dated 12/3/2025 documented a post-op visit with an orthopedic specialist scheduled for 12/12/2025 at 1:45 PM. The resident’s significant other later reported concern that this follow-up appointment had been missed, which was documented in the Interdisciplinary Documentation on 12/12/2025, noting that the orthopedic office would need to be contacted and a new post-op follow-up appointment made. Further review of the resident’s record showed that the follow-up orthopedic visit did not occur until 12/24/2025. The Medical Records Manager stated that she had been on leave at the time of the resident’s admission and that another staff member was covering her duties. She reported that the After Visit Summary should have been reviewed at admission and necessary follow-up appointments scheduled, but her logs contained no documentation that the post-op appointment was noted or scheduled at that time. The DON reported being uncertain why the resident missed the original post-op appointment and was unable to find documentation explaining how it was missed.
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