F0684

D

Failure to Schedule Urology Appointment After Abnormal PSA Result

Rockford, Illinois Survey Completed on 03-09-2026

Penalty

No penalty information released

Summary

The facility failed to provide appropriate treatment and care according to provider orders and resident preferences by not scheduling a urology appointment for one resident after an abnormal lab result. The resident’s prostate specific antigen (PSA) lab result dated 5/14/25 showed a high value, and the nurse practitioner documented on the lab result form that the resident should be referred to urology. An order dated 5/16/25 for a referral to urology related to the high PSA was present on the resident’s active Order Summary Report as of 5/19/25. The DON confirmed that the nurse practitioner had written for the resident to see a urologist and stated that the referral should have been placed in the medical appointment scheduler’s mailbox so the appointment could be made. The medical appointment scheduler reported that no urology appointment had been scheduled for the resident and that there were no entries in the appointment schedule book, stating he believed the appointment was not made because he was never notified of the order or referral. Review of the resident’s electronic medical record by the DON showed no indication that the resident had seen a urologist.

This sequence of events demonstrates that despite a documented high PSA result and a corresponding provider order for a urology referral, the internal process for communicating and acting on the referral order failed, resulting in the resident not receiving the ordered urology consultation.