Failure to Implement Oncology Referral Order Resulting in Delayed Cancer Treatment
Penalty
Summary
The facility failed to implement an oncology referral ordered for a resident upon discharge from a General Acute Care Hospital (GACH). The resident, who had diagnoses including dementia and malignant pleural effusion, was readmitted to the facility with a Hospitalist Discharge Summary and Transfer Instruction (HDSTI) dated 1/6/26 that included an order to refer the resident to oncology. The resident’s cognition was documented as severely impaired on the Minimum Data Set, limiting her ability to advocate for herself. The facility’s Social Services Assistant stated that on 1/14/26, the resident’s family member brought the oncology referral order in the HDSTI to her attention, and that prior to this, the facility was not aware that the resident needed an oncology referral. Review of the facility’s Physician’s Orders dated 1/7/26 showed no order for an oncology referral, despite the HDSTI containing such an order. During an interview, the DON acknowledged that the HDSTI ordered an oncology referral while the facility’s Physician’s Orders did not, and stated it was the reviewing nurse’s responsibility to follow up with the facility physician regarding the oncology referral. The facility’s policy titled “Transportation schedule” required a licensed nurse to check the physician order sheet for any existing orders for medical appointments, consults, or procedures provided outside of the facility. The failure to act on the oncology referral resulted in a delay in the resident’s cancer treatment until the family member intervened on 1/14/26, and the DON acknowledged that this failure could cause a worsening of the resident’s malignant pleural effusion.
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