The resident at Fountain View Subacute and Nursing Center missed appointments on October 21, November 6, December 3, and December 23, according to a care coordinator from an external clinic who contacted inspectors. The December 23 appointment was for a CT scan.
The resident attended only one appointment during this period, on December 24.
A care coordinator who functions as a case manager told inspectors that a social worker from the facility was previously contacted about escort services. But there had been a change in personnel, and the resident no longer received those services.
The physician from the external clinic informed the care coordinator about the missed appointments. When the care coordinator followed up with Fountain View, facility staff indicated they were unaware the appointments had been scheduled.
During the inspection, the Director of Nursing described the facility's process for ensuring residents attend appointments. When residents return from outside clinics, they receive new orders or follow-up dates. Nurses then create an order, communicate among themselves, and hold a huddle.
"The expectation is that when residents return, they have progress notes from the doctor, follow-up appointments, or new orders," the Director of Nursing said.
The Director of Nursing acknowledged that failure to document new orders and follow-up appointments delayed treatment for the resident. This potentially caused health deterioration, unmet care needs, and a lack of quality of life.
The Administrator told inspectors the facility can send a Certified Nursing Assistant or Activity Staff member to escort residents to appointments.
"Lack of staff is not a reason to miss resident appointments," the Administrator said.
The Administrator explained that two social workers recently left the facility. They hired the current social service worker four months ago and are awaiting another hire to help manage the high workload.
Fountain View's own policy requires the facility to assist in scheduling appointments and arranging transportation for residents. If needed, arrangements must be made for someone to accompany residents to appointments.
The policy states that licensed nurses should document a resident's departure and clinical condition on the day of the appointment and when they return. Any new orders and follow-up appointments must be documented in the electronic health record, with Medical Doctor progress notes included in the resident's medical record.
The facility violated federal regulations requiring nursing homes to ensure residents receive necessary care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being.
Inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents.
The missed appointments represent a breakdown in the basic coordination of medical care. CT scans are diagnostic imaging tests that use X-rays and computers to create detailed, cross-sectional images of bones, organs, and soft tissues. They help doctors diagnose diseases, plan treatments, guide procedures like biopsies, and monitor conditions such as tumors, injuries, and internal bleeding.
For nursing home residents who often have multiple chronic conditions requiring regular monitoring, missing scheduled medical appointments can lead to delayed diagnosis of complications, progression of untreated conditions, and unnecessary hospitalizations.
The case illustrates how staffing changes and communication breakdowns can directly impact resident health outcomes. The facility's acknowledgment that they were "unaware" of scheduled appointments suggests gaps in their care coordination systems.
The Administrator's statement that lack of staff is not a reason to miss appointments contrasts with the reality that two social workers recently left and the facility is struggling with high workload while awaiting new hires.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fountain View Subacute and Nursing Center from 2025-12-29 including all violations, facility responses, and corrective action plans.
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