Failure to Escort Resident to Medical Appointment
Penalty
Summary
The facility failed to ensure adequate supervision for a resident, identified as Resident 2, who was at risk for elopement and falls due to cognitive loss and lack of safety awareness. The resident's care plan included the use of a Wander Guard device to prevent elopement and required that the resident not leave the facility without an escort. Despite these precautions, Resident 2 attended an out-of-facility urology appointment without being accompanied by facility staff, due to a miscommunication that resulted in the assigned escort, a Nurse Aide, remaining at the facility. Resident 2's medical history included obstructive uropathy and chronic kidney disease, conditions that necessitated regular medical appointments. The failure to provide an escort for the resident's appointment was a direct violation of the facility's policy on transportation and escort services, which mandates that staff may escort patients if needed. This oversight was confirmed during an interview with the Nursing Home Administrator, who acknowledged that Resident 2 should not have been left unattended at the appointment.
Plan Of Correction
Resident 2 had no ill effect for not having an escort to his appointment. Residents with scheduled transport in the last week will be audited to ensure residents who needed escorts were escorted to their appointments. The Director of Nursing / Designee will educate licensed staff on Ftag 0689 free of accident/Hazard/Supervision/Devices focusing on residents escorts to appointments. Audits of 5 random residents with scheduled appointments will be completed by unit managers / designee per week for 4 weeks to ensure residents who need escorts have arranged escorts. Results of the audits will be reviewed by the QAPI committee for recommendations.