F0684

D

Failure to Schedule Timely Cardiology Follow-Up per Discharge Instructions

Port Jervis, New York Survey Completed on 03-30-2026

Penalty

No penalty information released

Summary

The facility failed to ensure that a resident received treatment and care in accordance with professional standards and hospital discharge instructions related to a required cardiology follow-up. Resident #17, who had diagnoses including cerebral infarction, occlusion and stenosis of the left carotid artery, and myocardial infarction, was discharged from the hospital on 02/05/2026 with written instructions to schedule a follow-up appointment with cardiology within one month. The admission Minimum Data Set documented that the resident had moderately impaired cognition and that the resident and family were involved in assessment and goal setting. Despite these instructions, the follow-up cardiology appointment was not scheduled within the specified timeframe.

During interviews, Resident #17's representative reported that they had discussed the hospital discharge instructions and the need for a cardiology appointment with the Director of Nursing but did not receive assistance, resulting in a delay in scheduling. The representative stated that only with persistence were they able to get the appointment scheduled for 04/01/2026, beyond the one-month timeframe indicated in the discharge instructions. The Director of Nursing acknowledged that the representative had informed them of the need for a cardiology consultation and stated that the appointment should have been scheduled sooner, but they did not see the follow-up requirement on the discharge summary and were unaware of additional discharge papers documenting the need for the cardiology follow-up. This sequence of events led to the resident not receiving timely follow-up care as ordered.