Failure to Arrange Transportation for Resident
Summary
The facility failed to assist Resident G in obtaining transportation from a hospital appointment, resulting in the resident being left without a way to return to the facility. On 5/28/24, Resident G was sent to the hospital for an MRI and was assured by a nurse that his transportation was arranged. However, after completing the MRI, Resident G was left outside the hospital as the transportation van did not arrive. Despite his attempts to contact the facility for assistance, no one answered his calls for about 30 minutes. An off-duty employee of the facility, who happened to see Resident G outside the hospital, eventually brought him back to the facility. Interviews with facility employees revealed a lack of communication and coordination regarding Resident G's transportation. Employee 3, who encountered Resident G at the hospital, observed him making multiple unsuccessful calls to the facility. Upon contacting the facility, Employee 3 was informed by a supervisor that no one was aware of the transportation arrangements. Additionally, Employee 5 confirmed that there was confusion among staff about who was responsible for Resident G's pickup, and no one had the transportation company's contact information. Resident G's medical record indicates he has multiple diagnoses, including paraplegia, diabetes, generalized anxiety disorder, and major depressive disorder, which may have exacerbated his distress during the incident.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with multiple complex conditions, including CHF, DMII, morbid obesity, and chronic respiratory failure, who was cognitively intact but dependent on staff for several ADLs and used a wheelchair, was transported to the wrong location for a scheduled PET scan. Appointment documentation from a cardiology visit listed one testing site and time, while the physician order in the facility record listed a different site and date, resulting in the resident being taken to the incorrect testing center and missing the scan. The resident and spouse later contacted the facility from the wrong location and ultimately chose to walk back rather than wait for arranged transportation, contrary to the facility’s transportation policy that requires arranging and ensuring transport to and from outside appointments.
Failure to Provide Accurate Transportation for Outside PET Scan Appointment
Penalty
Summary
The facility failed to ensure adequate transportation was provided for an outside radiology appointment for Resident #96. The resident, admitted on 10/03/24, had diagnoses including acute chronic systolic heart failure, type II diabetes mellitus, morbid obesity, chronic respiratory failure, and major depression bipolar disorder. An MDS assessment dated [DATE] showed she was cognitively intact but dependent on staff for toileting, bathing, footwear, and turning in bed, and she used a wheelchair for mobility. Nursing progress notes confirmed multiple outside appointments, including a PET scan scheduled for 04/03/25. The after-visit summary from a cardiology appointment on 04/03/25 documented a PET scan scheduled at a testing location in Columbus, Ohio at 2:00 P.M., but the physician order in the medical record listed the PET scan for 04/16/25 at a different testing location in [NAME], Ohio at 1:30 P.M. A concern form completed by the Administrator documented that on 04/03/25 the resident was taken to the wrong testing center for the PET scan, causing the test to be missed and requiring rescheduling. A written statement by the Administrator dated 04/16/25 confirmed a transportation mistake was made for the 04/03/25 appointment and that the resident and her spouse contacted the facility to arrange pick-up from the incorrect location. During an interview, the Administrator confirmed the resident was taken to the wrong location and that Administrator Assistant #596 worked with the resident to ensure her return to the facility, but the resident and her spouse did not wait for transportation and decided to walk back to the facility. Review of the facility’s Transportation policy dated 08/24 showed the facility was responsible for arranging and ensuring transportation to and from outside appointments based on information received from the resident, family, transportation company, or doctor’s office. This failure affected one of three residents reviewed for transportation to outside appointments, with a facility census of 80, and was investigated under Complaint Numbers 2572222, 1376015 (OH00165472), and 1376014 (OH00165055).
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