Resident Misses Appointment Due to Lack of Assistance
Summary
The facility failed to provide necessary assistance with grooming and dressing for a resident who had a scheduled physician's appointment, resulting in the resident missing the appointment. The facility's policy on resident rights emphasizes the importance of assisting residents in maintaining their self-esteem and ensuring reasonable accommodation of their needs. However, the resident, who was dependent on staff for dressing and bathing due to conditions such as osteomyelitis, peripheral vascular disease, and diabetes, did not receive the required assistance in a timely manner. This lack of assistance led to the resident being unprepared when transportation services arrived, causing her to miss her medical appointment. The resident, who had intact cognition as indicated by a BIMS score of 15, expressed that she missed her appointment because she was not helped in time to get ready and reach the transportation service. Interviews with the resident and staff, including the Director of Nursing and a Certified Nurse Assistant, confirmed that the resident required substantial assistance for dressing and that staff should have provided timely help. The Director of Nursing acknowledged that the resident does not move quickly and should have been assisted to ensure she was ready for her transportation.
Penalty
Resources
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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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