Failure to Provide Safe Transportation for Cognitively Impaired Resident
Summary
The facility failed to provide safe transportation for a resident with severe cognitive impairment and physical disabilities, resulting in the resident being dropped off alone at the wrong address. The resident, who had a BIMS score indicating severe cognitive impairment, required maximum assistance for mobility and had significant medical conditions, including hemiplegia, memory deficit, and dysphagia. Despite these needs, the Transportation Supervisor dropped the resident off at an incorrect location without ensuring a family member was present to meet him. The Transportation Supervisor admitted to the mistake and stated that she was not informed by the facility about the resident's need for supervision during transportation. The Social Services Director and Administrator both acknowledged that the resident should not have been left alone due to his cognitive and physical limitations. The facility's policy on transportation required that any special considerations be documented in the resident's clinical record, but this was not effectively communicated or adhered to, leading to the incident.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with ESRD, DM, and severe vision loss missed multiple specialty appointments because transportation was not scheduled on time. Records and interviews showed the ride request for an endocrinology visit was sent after the vendor’s cutoff, no ride was on file, and the DON confirmed missed endocrinology and GI appointments with no documentation explaining the absences.
A resident with impaired cognition and diagnoses including HIV, bipolar disorder, and substance use disorders missed multiple HIV clinic appointments because of transportation problems, lack of staff escort, and missing documentation of attendance. The DON verified that not all appointments were attended, and the facility policy required support and facilitation of transportation to necessary medical appointments.
Failure to assist a resident with transportation to a diagnostic appointment. A resident with intact cognition, multiple cardiac and mobility-related diagnoses, and substantial ADL assistance needs was told to arrange her own transportation for an early-morning stress test. Staff posted a hallway sign directing residents to schedule their own transportation for appointments before 8 AM unless arranged in advance, and both CNA and admin staff stated the resident was expected to handle her own ride because she was known to make her own appointments, despite facility policy stating transportation would be arranged as needed.
A resident with an AKA, difficulty walking, HTN, and DM was scheduled for outside appointment transportation and return by wheelchair van, but after the appointment ended she and a CNA waited in the lobby for hours when the ride did not arrive. The resident reported repeated unanswered calls to the facility, being told by the transport company she was a no show, and remaining in the lobby without food, water, or restroom access until a later ride arrived after 7 p.m. The DON stated the facility should have had a system in place to get the resident back when she was not picked up as expected.
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 ESRD and HD dependence experienced repeated late transportation to dialysis, including one trip where the ambulance arrived late and the return was also delayed. The resident reported the dialysis center had the resident sign paperwork because the treatment was shortened, and records showed the HD session was cut short by 24 minutes due to late arrival. Staff interviews confirmed the CM did not follow the ordered pickup time, and the LVN was unaware the treatment had been shortened.
Missed Specialty Appointments Due to Late Transportation Scheduling
Penalty
Summary
The facility failed to ensure transportation was scheduled and provided for a resident’s medical appointments outside the facility, resulting in missed specialty visits. Resident #1 had diagnoses including end stage renal disease, diabetes mellitus, gastroesophageal reflux disease, and severely impaired vision with only light, colors, or shapes seen, while cognition was intact with a BIMS score of 15. Records showed an endocrinology appointment scheduled for 4/9/26, but the April 2026 progress notes did not document that the visit occurred. A later endocrinology note showed another appointment scheduled for 6/18/26, and a progress note documented that the endocrinology clinic called to report the resident missed that appointment and arranged a virtual visit instead. Interview and record review showed the transportation request for the 4/9/26 endocrinology appointment was faxed at 8:55 PM on 4/8/26, after the transportation vendor’s 4:00 PM cutoff for next-day scheduling. The vendor reported no ride was scheduled for that date. The DON confirmed the resident missed the 4/9/26 endocrinology appointment due to late transit setup and also missed a gastroenterology appointment on 4/23/26, with no record documentation explaining the absence. The DON stated the corporation had eliminated the facility scheduler position, the previous scheduler had discarded resident appointment papers, and the facility had no policy for its scheduling process.
Missed Medical Appointments Due to Transportation Failures
Penalty
Summary
The facility failed to ensure physician appointments were attended for Resident #27, who was admitted with diagnoses including alcohol dependence with alcohol-induced persisting dementia, anxiety, HIV, bipolar disorder, and cocaine abuse. The quarterly MDS showed impaired cognition and that the resident was independent with transferring and ambulation. The care plan identified the resident as non-compliant with care and treatment as ordered by the physician, with interventions to educate the resident on not following physician orders and to observe and document behavior changes. Review of the appointment schedule and HIV clinic records showed multiple missed, cancelled, or unverified clinic visits. The facility was unsure whether the resident attended some appointments because there was no documentation, several appointments were rescheduled or cancelled due to transportation issues, one appointment was missed because transportation arrived in a vehicle too small to transport the resident, and another was missed because no staff escort was available. The DON verified that the resident did not attend all appointments and stated some were missed due to transportation, while the facility policy required support and facilitation of proper transportation to necessary medical appointments.
Failure to Assist Resident With Transportation to Diagnostic Appointment
Penalty
Summary
The facility failed to assist a resident with transportation to a radiology appointment and related diagnostic services. The resident had multiple diagnoses including atherosclerotic heart disease, seizures, anxiety disorder, cardiac pacemaker, rheumatoid arthritis, reduced mobility, muscle weakness, heart failure, difficulty walking, unsteadiness on feet, and need for assistance with personal care. The resident’s MDS documented a BIMS score of 15, indicating intact cognition, and the resident used a walker and manual wheelchair. The resident also required substantial to maximal assistance with several ADLs, including toileting hygiene, bathing, dressing, footwear, and personal hygiene, and the care plan directed one staff member’s assistance with transfers. The facility transportation calendar showed the resident had appointments scheduled, including a physician-ordered heart perfusion stress test. The resident’s EMR lacked progress notes for the appointment and the upcoming test. A sign posted outside the resident’s room stated that appointments before 8 AM required residents to schedule their own transportation unless arranged with a CNA two weeks in advance. The resident stated she was told staff would not take her to the appointment because it was made at the last minute, and she felt stressed by having to arrange her own transportation. A CNA confirmed the resident was told to find her own transportation because of the early appointment time and the CNA’s work schedule. Administrative staff stated the resident was known to make her own appointments and therefore needed to arrange her own transportation, while also acknowledging that if the physician set up the appointment, the facility should handle transportation. The facility’s transportation policies stated that the community would help arrange transportation for residents as needed and assist with transportation to diagnostic appointments when necessary.
Delayed Return Transportation After Outside Appointment
Penalty
Summary
The facility failed to ensure transportation back to the facility for a resident who had an outside medical appointment and was scheduled for return transportation. Resident 2 was admitted with diagnoses including a left above-knee amputation, difficulty walking, hypertension, and type 2 diabetes with other circulatory complications. Her MDS indicated she was cognitively intact, required partial/moderate assistance with several activities of daily living, and used a wheelchair for mobility. The transportation request showed she was to be taken to the appointment by a transportation company and picked up for return to the facility later that day. Resident 2 stated that after her appointment ended, she and CNA 3 waited in the medical facility lobby for transportation that did not arrive. She reported calling the transportation company and being told she was a no show, then calling the facility multiple times between mid-afternoon and early evening without reaching anyone at the nursing station. She stated that around 6 p.m. a security guard asked her and CNA 3 to leave because the facility was closing, but allowed them to remain in the lobby because the doors would lock if they left. She remained there without food, water, or restroom access until transportation arrived after 7 p.m. The transportation company supervisor stated the van attempted pickup at 3:41 p.m., but Resident 2 was not there and no one answered when they called her phone, so the driver left. The facility’s SSS and SSD stated they were notified after the missed pickup and attempted to arrange another ride, but transportation was not available until 7 p.m. CNA 3 stated she called the facility and was told to wait while the ride was rescheduled, and later her phone battery died. The DON stated the facility should have had a system in place to get the resident back when she was not picked up at the expected time. The facility policy stated it would help with transportation for residents as needed.
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.
Late Dialysis Transportation Resulted in Shortened Treatment
Penalty
Summary
The facility failed to ensure transportation to and from outside laboratory services was not late for a resident who depended on hemodialysis. Resident 190 was admitted with acute respiratory failure with hypoxia and end stage renal disease with hemodialysis dependence. The resident’s MDS showed intact cognition with a BIMS score of 14, and the resident required varying levels of assistance with activities of daily living, including dependence for transfers, toileting, and showering. During interview, Resident 190 stated that transportation for dialysis had been late on multiple occasions. The resident reported that on one occasion the ambulance arrived one hour late for pickup and 45 minutes late for return to the facility, and that the dialysis center had the resident sign paperwork because the treatment was shortened. On another day, the resident was still waiting in the room for transportation and stated the dialysis time was being shortened because of the delays. EMT 1 stated dispatch provided pickup and destination information but not an exact pickup time. Record review showed the facility arranged transportation for a 9:30 a.m. dialysis start time with pickup at 8:30 a.m. or 9:00 a.m., while the physician’s order dated 4/29/2026 indicated pickup time of 8:15 a.m. The dialysis communication record and AMA form dated 5/11/2026 showed the resident’s dialysis treatment was shortened by 24 minutes from the prescribed 195 minutes due to arriving late. Staff interviews showed the CM did not know the ordered pickup time, the LVN was not aware the treatment had been cut short, and the DON stated the CM did not follow the resident’s care plan or order for dialysis transportation.
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