Failure to Provide Escort for Resident's Medical Appointment
Summary
The facility failed to arrange appropriate transportation for a resident, leading to a missed oncology appointment. The resident, a male with a history of acute respiratory failure, emphysema, malignant neoplasm of the larynx, COPD, severe protein-calorie malnutrition, and behavioral disturbances, required an escort due to his behavior and elopement risk. On the day of the appointment, the transportation was arranged, but no escort was available to accompany the resident, making it unsafe for him to attend the appointment alone. The transportation coordinator, who usually accompanies residents, was on a scheduled day off and had informed the scheduler and the Director of Nursing (DON) about the need for an escort. Despite the transportation being set up, the facility did not provide an escort, resulting in the appointment being missed. The facility's appointment log incorrectly documented that no escort was needed, although the transportation coordinator confirmed that the facility was aware of the requirement. Interviews with the DON and the scheduler revealed that while the facility offers escort services, they do not guarantee them and have no specific policy or protocol for providing escorts. The facility was unable to provide any policy or documentation regarding transportation arrangements during the survey.
Penalty
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A resident missed a dental appointment because transportation was not arranged correctly, and the appointment had to be rescheduled. The resident said multiple appointments had been missed in the past. Staff reported confusion over whether the MCO or the facility was responsible for scheduling transportation, and noted prior issues with appointment and transportation coordination.
A resident with paraplegia and a baclofen pump experienced multiple missed and delayed pre‑op and surgical appointments due to unreliable transportation coordination. The facility failed to schedule a ride and complete required blood work for one pre‑op visit, did not hold the resident’s Eliquis in time for another attempt, and a transportation company arrived with an inappropriate vehicle instead of a wheelchair van on a subsequent occasion. Progress notes and an APNP note documented that the pre‑procedure physical and baclofen pump replacement surgery were delayed multiple times because of transportation issues. Transportation staff, the RN, DON, and NHA acknowledged missed appointments and transportation problems, and the surveyor was not provided with staff education for the updated transportation process when requested.
A resident with mild cognitive impairment and malignant neoplasm of the mouth missed multiple outside oncology and infusion appointments because staff did not arrange transportation in accordance with the facility’s appointments and transportation policy. Records showed that the resident was transported only to a cardiology visit while scheduled oncology and infusion appointments on the same day, as well as a separate oncology appointment, were not attended. An oncology clinic NP reported that the resident missed several appointments with various providers and that the resident attributed these missed visits to lack of transportation, poor communication, and failure to document appointments for staff follow-up, while the DON acknowledged that staff are responsible for setting up such appointments.
The facility failed to ensure staff who operated the resident transport van were assessed and documented as competent, despite using the vehicle to take residents to medical appointments and activity outings. A staff member and the AD reported routinely transporting residents, including wheelchair-bound individuals, using a van equipped with a hydraulic lift and wheelchair restraints, without ever being required to demonstrate driving competency or safety. The DSD confirmed there was no process to verify driver competency, and the DON acknowledged that no competencies had been completed for staff who drive the van, contrary to the facility’s own competency evaluation policy requiring staff providing care, treatment, or services to be competent.
Failure to transport a resident to a scheduled wound center appointment resulted in a missed wound care visit. The resident had moderate cognitive impairment, hypertension, acute respiratory failure, weakness, and skin breakdown to the buttocks after a hospital transfer for altered mental status. Hospital discharge instructions included wound center follow-up, but the facility’s records did not show transportation, a wound center visit, or future appointment documentation, and the wound center reported the resident was a no show with no follow-up communication from the facility.
A resident with a right humerus fracture, lumbar fractures, and other comorbidities had a physician-ordered orthopedic follow-up appointment requiring accompaniment by medically trained staff. On the morning of the appointment, the resident was observed dressed, with arm in a sling and appointment papers in hand, waiting in the doorway and later still in the room, reporting that no one came to take him to the visit and that the appointment was missed. Review of records and appointment paperwork confirmed the scheduled follow-up and staff accompaniment requirement, and an RN acknowledged the resident was not transported due to miscommunication with the physician’s office.
Missed Dental Appointment Due to Transportation Issues
Penalty
Summary
The facility did not assist a resident with arranging transportation to and from an outside dental appointment, resulting in the resident missing the appointment on 4/16/26 and needing to reschedule because of transportation issues. The resident stated that multiple appointments had been missed in the past. The resident was admitted with diagnoses including chronic pain syndrome, anxiety disorder, post-traumatic stress disorder, and contusion of the left upper arm. Surveyor review of records showed a progress note from the Director of Social Services documenting that the resident missed the dental appointment due to transportation issues. The Director of Social Services stated there had been a conversation with the resident about the dental appointment and that transportation problems caused the rescheduling. The Director also stated there had been confusion in the past about whether the resident's Managed Care Organization or the facility was responsible for scheduling transportation. The Receptionist stated there had been previous issues with transportation and scheduling the correct transportation services, and the Nursing Home Administrator stated there had been past issues with scheduling appointments and transportation.
Failure to Ensure Reliable Transportation for Baclofen Pump Services
Penalty
Summary
The deficiency involves the facility’s failure to provide reliable transportation for a resident requiring outside laboratory and surgical services for a baclofen pump change. The resident, who had paraplegia, a T1 spinal cord injury, anxiety, and depression, was cognitively intact with a BIMS score of 15/15. According to the resident’s interview, there were multiple missed or unsuccessful attempts to complete the necessary pre‑operative and surgical appointments, and the resident only reached the appointment on the fourth attempt. The resident reported that the first appointment was missed because the facility did not schedule a ride for the pre‑op visit and did not complete the required blood work, the second attempt failed because the facility did not hold the resident’s Eliquis in time, and the third attempt failed when the transportation company arrived with a car instead of a wheelchair van. Progress notes documented that a pre‑procedure physical appointment was missed due to transportation issues, and an APNP note stated that the baclofen pump replacement surgery had been delayed multiple times due to transportation problems. Staff interviews further confirmed issues with transportation coordination and reliability. Transportation staff reported using several different transportation companies and were unaware of the specific transportation failures for this resident, and could not explain what happened with at least one missed appointment, noting that another former transportation staff member might have kept notes elsewhere. A RN acknowledged there had been a few missed appointments recently and confirmed that at least one of this resident’s appointments was missed when the ride did not show up, despite the resident being ready. The DON confirmed there were issues with a transportation company, and the NHA stated that transportation scheduling and approval processes were in place, including a binder and electronic dashboard for appointments, but staff education for the updated transportation process was not provided to the surveyor when requested.
Failure to Arrange Transportation for Oncology and Infusion Appointments
Penalty
Summary
The deficiency involves the facility’s failure to follow its appointments and transportation policy by not arranging transportation for a resident’s outside oncology and infusion appointments. The resident is an adult male with mild cognitive impairment and an admitting diagnosis that includes malignant neoplasm of the mouth, as documented on the MDS. On one observation, he was noted in bed with swollen lips and was unable to communicate effectively. The facility’s policy, reviewed on 4/16/2025, states that when a resident has an appointment outside the facility, staff will make transportation arrangements unless the responsible party chooses to make them. The DON acknowledged not remembering why the resident missed appointments and stated that the resident has the right to go for an appointment and that staff are supposed to set it up. Record review showed that the resident had multiple scheduled outside appointments, including cardiology, oncology, and infusion visits. Physician orders documented that on 2/4/26 he was scheduled for a cardiology appointment at 9:05 AM, an oncology appointment at 12:00 PM, and an infusion appointment at 2:00 PM. The transportation schedule and nursing progress notes from 2/1/26 through 2/6/26 showed that he was sent only to the cardiology appointment and not to the oncology or infusion appointments. A review of the January transportation schedule and nursing progress notes from 1/25/26 through 1/30/26 further documented that he was not sent to an oncology appointment scheduled for 1/27/26 at 11:40 AM. The oncology clinic nurse practitioner reported that the resident missed around five appointments with various care providers, and that the resident stated he missed appointments due to lack of transportation, communication, and not writing the appointments in the records for staff to follow up after setting transportation. The nurse practitioner stated the resident is at high risk for relapse if he misses his oncology appointments.
Failure to Ensure Driver Competency for Resident Transport Vehicle
Penalty
Summary
The deficiency involves the facility’s failure to ensure that staff members who drive the facility’s transport vehicle were assessed and documented as competent to do so. During interviews, one facility staff member stated he had transported residents in the facility vehicle when asked by leadership, and employee file review showed another staff member also used the transport vehicle to transport residents. The DON confirmed that the facility provides transportation for residents to and from appointments and for activity outings. The DSD reported that facility staff, including two identified staff and activities staff, use the facility van for these purposes but stated there was no process in place to verify that these staff were competent and safe to operate the transport vehicle. The AD, who had worked at the facility for 15 years, stated that transporting residents on outings is part of her job and described the facility van as accommodating nine residents, including wheelchair-bound residents, with a hydraulic lift and wheelchair securement straps. She reported she had not been required to demonstrate competency or safety in driving the van. A concurrent observation with the DON confirmed the presence of a hydraulic lift and capacity for nine residents, including those who must remain in wheelchairs. The DON acknowledged that the facility had not completed competencies for staff who drive the transport vehicle. This practice was inconsistent with the facility’s written Competency Evaluation policy, which requires that all staff who provide care, treatment, or services be competent to perform their duties, with competency defined as the demonstrated knowledge and skill necessary to perform a task or job safely, successfully, and efficiently.
Failure to Transport Resident to Scheduled Wound Center Appointment
Penalty
Summary
The facility failed to transport Resident #23 to a scheduled wound center appointment for wound care. Resident #23 had a BIMS score of 11, indicating moderate cognitive impairment, and diagnoses that included hypertension, acute respiratory failure, and weakness. After a hospital transfer for altered mental status, nursing documentation noted skin alteration to the lower left buttock and red areas to the right buttock. Hospital discharge records directed follow-up with the wound center, primary care provider, and neurology, and a wound center appointment was scheduled for 12/2/25 at 9:45 AM. The resident’s nursing progress notes did not document transportation to the wound center appointment, a wound center visit, or future scheduled appointments. The wound center receptionist stated the resident was a no show for the appointment and that the facility did not provide follow-up communication. The DON later reported reviewing the hospital discharge document and seeing that a wound center appointment had been scheduled, but she could not find documentation showing whether the resident attended the appointment.
Failure to Transport Resident to Scheduled Orthopedic Appointment
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was transported to an outside orthopedic appointment as scheduled. The resident was admitted with multiple significant diagnoses, including a nondisplaced right humerus fracture, lumbar fractures at L1 and L2, morbid obesity, anxiety disorder, alcohol use, and a traumatic subdural hematoma from prior falls. The baseline care plan indicated the resident was alert and aware, non-weight bearing on the affected extremity, and was to receive physical and occupational therapy with the goal of discharge home, with social services coordinating services to achieve discharge goals. Physician orders documented an orthopedic follow-up appointment scheduled for 8:50 A.M. on 01/27/26, with instructions that staff accompaniment was required and that the accompanying staff needed to be medically trained. On the morning of the scheduled appointment, surveyor observation found the resident standing in the doorway with his right arm in a sling, wearing shoes and holding appointment papers, looking up and down the hallway shortly before the appointment time. In an interview, the resident stated he had been admitted about a week earlier, was supposed to have a follow-up with his orthopedic doctor that day, that his arm and sling were bothering him, and that no one had come to get him for the appointment. A later observation the same morning showed the resident still in his room with his arm in a sling, shoes on, and the appointment paperwork on the bedside table; he reported that no one ever came to get him and that he missed the appointment. Review of the appointment paperwork confirmed the scheduled orthopedic follow-up and the requirement for medically trained staff accompaniment. An RN interview verified the resident had not been transported to the appointment and attributed the missed appointment to miscommunication with the doctor’s office.
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