F0835

E

Failure of Administrative Oversight for Physician-Ordered Consults and Diagnostic Tests

Riverbank, California Survey Completed on 03-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the Administrator’s failure to provide effective oversight and necessary resources to ensure that physician-ordered consultations and diagnostic tests were scheduled, carried out, and documented in the electronic medical record (EMR) for multiple residents. The Administrator was the direct supervisor of the Social Services Director (SSD) and was responsible, per the job description, for directing day-to-day operations, ensuring policies and procedures were implemented, and reviewing the competence of the workforce. Despite this, the Administrator was not aware that the SSD was not consistently scheduling ordered appointments or documenting referral activities in the EMR, and allowed the SSD to maintain paper records in a personal folder and use a temporary communication board that was not part of the permanent medical record.

For one resident with COPD, dysphagia, and altered mental status, a physician ordered a Modified Barium Swallow (MBS) to rule out silent aspiration. Nursing documented that the SSD was notified of the order, and the expectation was that the SSD would schedule the test and document follow-up. However, there was no documentation in the EMR that the MBS was scheduled, completed, or refused, and the SSD later stated that the resident had refused the MBS and that the responsible party had also refused, but she had not documented this in the resident’s medical record. For another resident with seizures, dystonia, traumatic brain injury, and a gastrostomy, a physician ordered a Barium Swallow consult. Nursing notes indicated that the Social Services Assistant or SSD was notified, but the SSD acknowledged that although she contacted the resident’s sister and the hospital, she did not document her attempts to schedule the MBS or her contacts with the responsible party in the EMR, nor did she follow up with the speech therapist after being unable to schedule the test.

A third resident with hemiplegia, hemiparesis following cerebral infarction, dysphagia, aphasia, and a gastrostomy had physician orders for an ENT consult to assist with vocal cord mobility and an MBS to rule out silent aspiration and determine if oral diet was possible. The SSD stated that an in-house ENT consult had been scheduled but not documented in the EMR and that the MBS had not been scheduled because they were waiting for the ENT consult and insurance authorization. The SSD did not document any attempts to obtain authorization, schedule the MBS, or notify the speech therapist or primary physician of delays. The SSD described a referral process in which orders were left under her office door when she was absent and acknowledged that she did not routinely document referral attempts or follow-up in the EMR, instead keeping papers in a folder and using a communication section of the EMR that was automatically cleared and not part of the permanent record. The facility’s policy required Social Services to collaborate with nursing to arrange ordered services and to document referrals in the resident’s medical record, but this was not done. The Administrator confirmed that he was aware the SSD was documenting on paper and in a non-permanent communication board, and that he expected physician orders to be followed and referrals documented, but he had not ensured that this occurred, resulting in ordered consultations and tests for several residents not being timely scheduled or properly documented.

The surveyors also observed one resident with a gastrostomy lying in bed with an enteral feeding pump at bedside not connected to the gastrostomy tube, and this resident was verbally nonresponsive. While this observation did not directly reference a missed order, it occurred in the context of broader concerns about the facility’s management of residents requiring specialized nutritional support and diagnostic evaluation for swallowing. Across the reviewed cases, there was no evidence in the EMR of timely scheduling, follow-up, or clear documentation of refusals or barriers to completing ordered tests and consultations. The SSD herself stated that if something was not documented, it was considered not done, and acknowledged that she should have documented her attempts and follow-up in the EMR so they would be part of the medical record. The Administrator’s lack of effective oversight and failure to ensure adherence to the facility’s referral and documentation policies contributed to these gaps in care coordination and recordkeeping for multiple residents.

The facility’s written policy on Social Services referrals required that referrals for medical services be based on physician evaluation, that Social Services collaborate with nursing and other disciplines to arrange ordered services, and that Social Services document the referral in the resident’s medical record. The Administrator’s job description required development and maintenance of policies and procedures, routine inspections to ensure implementation, consultation with department directors to correct problem areas, and review of staff competence. Despite these requirements, the Administrator did not detect or correct the SSD’s practice of using non-medical-record systems (paper folders and a temporary communication board) for tracking referrals, did not ensure that physician orders for MBS and ENT consults were carried out, and did not ensure that all referral-related activities were documented in the EMR. This lack of administrative oversight and failure to enforce established policies led to physician-ordered consultations and tests for several residents not being timely scheduled or properly documented in the medical record.