Failure to Arrange Ordered Lymphedema Clinic Follow-Up
Penalty
Summary
The deficiency involves the facility’s failure to provide medically-related social services by not arranging a needed follow-up appointment with a lymphedema clinic for one resident. The resident was admitted with diagnoses including heart failure, a history of DVT, and lymphedema. An MDS dated 2/26/26 documented these conditions, and the care plan for high blood pressure and CHF directed staff to observe for signs and symptoms such as SOB, chest pain, edema, and elevated blood pressure. The care plan for actual/potential risk for skin integrity impairment was updated on 3/6/26 to include lymphedema. Multiple provider notes documented the need for a lymphedema clinic follow-up. A nurse practitioner’s note dated 2/24/26 listed lymphedema and specified that the resident, who was on diuretics, needed follow-up with a lymphedema clinic. A physician’s note dated 2/25/26 and another nurse practitioner’s note dated 3/3/26 both reiterated that the resident had chronic lymphedema, was on diuretics, and needed outpatient follow-up with a lymphedema clinic. Review of the clinical record showed no order for this appointment and no attempt to schedule it. In interviews, an RN confirmed the resident was not provided a follow-up appointment, and the Nursing Home Administrator confirmed the facility failed to schedule the follow-up, constituting noncompliance with 28 Pa. Code 211.16(a) regarding social services.
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