Failure to Inform Residents of Treatment Changes and Missed Follow-Up Care
Penalty
Summary
The facility failed to ensure residents were fully informed about their health status, care, and treatments, and failed to arrange a necessary follow-up appointment. One resident with intact cognition and diagnoses including diabetes, chronic pain, depression, and a recent left above-knee amputation was discharged from the hospital with orders for a follow-up appointment with a vascular nurse practitioner and was prescribed Oxycodone-Acetaminophen 7.5-325 mg every 6 hours for pain. A subsequent physician order decreased this pain medication to 5-325 mg every 6 hours, but the clinical record contained no documentation that the resident was notified of this change. The resident reported he only realized his pain medication had been decreased when he noticed the pills were a different color and was then told by a nurse that the nurse practitioner had decreased the dose. The clinical record also lacked documentation that the resident was informed of the original follow-up appointment, the need to reschedule it, or any related communication. The same resident’s hospital discharge orders included a follow-up appointment on 2/16/26 with the vascular provider, but the vascular center reported the facility made no contact to reschedule after the resident was listed as a no call/no show for that appointment. The appointment was later rescheduled after involvement from an external social worker, and the resident ultimately arrived late but was still seen for suture removal. In a separate case, another resident with dementia and lack of coordination had been receiving therapy services. The resident’s representative stated she had requested therapy to help increase the resident’s strength and had not observed any therapy being provided, nor had she been notified about the status of therapy. The physical therapist reported working with the resident for about a month, stated that maximum potential had been reached, and that the resident was discharged from therapy, but he did not notify the family and instead relied on nursing staff to do so. The clinical record lacked documentation that the resident or representative was notified of the discontinuation of therapy services.
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