Failure to Complete Ordered Cardiology Follow-Up for Resident With CHF
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for cardiology follow-up for a resident with congestive heart failure (CHF) and elevated BNP levels. Physician progress notes dated November 7, 2025, documented that the resident had CHF with BNP levels in the 1000s and that a cardiology follow-up was due, with a referral placed and discussed with the facility and scheduler. A physician order dated November 6, 2025, directed a cardiology follow-up, but there was no documented evidence that this consult was completed. The resident continued to experience shortness of breath and required supplemental O2, and a new medication was ordered while CHF remained the primary assessment. On December 8, 2025, nursing progress notes documented a new NP order for cardiology follow-up for CHF, and a corresponding physician order for cardiology follow-up was entered the same day. Physician progress notes on December 10, 2025, again stated that the resident needed cardiology follow-up and that this need had been discussed with the facility for scheduling. Nursing notes on December 11, 2025, indicated that cardiology had been called twice and messages left to schedule an appointment, with staff awaiting a return call. However, there was no documented evidence that the cardiology consult ordered on December 8, 2025, and referenced on December 11, 2025, was ever completed. During an interview, the DON stated that a cardiology consult had been scheduled but the resident could not attend due to illness and was unable to provide documentation of this, resulting in a failure to ensure that the cardiology follow-up orders were followed.
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