Failure to Arrange Transportation Results in Missed Post-Op Appointment and Harm
Summary
The facility failed to arrange transportation for a resident to attend a post-operative medical appointment, resulting in the resident missing a scheduled staple removal following an amputation surgery. The resident, who had a history of major orthopedic surgery, bilateral lower extremity impairment, and pain management needs, was admitted with multiple complex diagnoses including diabetes, atherosclerosis, and surgical site complications. Documentation showed that the resident's appointment was rescheduled without notifying the family, and ultimately canceled due to transportation not being arranged by the facility. The family was not informed of the changes, and the resident reported that transportation was never scheduled. Interviews with staff and review of records revealed that the unit clerk responsible for transportation coordination was aware of the appointment but did not ensure transportation was arranged. The resident experienced pain and reported tightness around the surgical staples, which became embedded due to the missed appointment. The facility did not provide requested documentation of appointment and transportation forms, and the Director of Nursing confirmed that a log should be maintained to track appointments and transportation, which was not effectively done in this case.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
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 Medical Appointment Due to Lack of Transportation: A resident with injuries from an MVA, multiple fractures, and ongoing pain missed a needed pain management-related nerve conduction study because facility transportation was not arranged when the van was unavailable. The SSD said the appointment was cancelled due to the van being inoperable and waiting for new registration tags, and there was no documentation that the missed appointment was addressed or rescheduled.
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.
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.
Missed Medical Appointment Due to Lack of Transportation
Penalty
Summary
The facility failed to ensure Resident 64 could attend a needed medical appointment when transportation was not arranged, causing the appointment to be cancelled and not rescheduled. Resident 64 was admitted with diagnoses including injuries from a motor vehicle accident, multiple rib fractures, pain in unspecified joint, pain in both shoulders, muscle spasm, and dysphagia. His MDS dated 2/4/26 showed a BIMS score of 13 with no cognitive impairment. Resident 64 stated during interview that he had constant pain after his accident and had missed a pain management appointment because of facility transportation issues that had been ongoing for about a year. Record review showed no Social Services progress notes about the missed appointment. A list of missed medical appointments showed that Resident 64 missed a nerve conduction study scheduled at a hospital on 3/18/26 and it had not yet been rescheduled. The SSD stated the appointment was cancelled because the facility van was not operable and the facility was waiting for new registration tags, and she had not documented progress notes about the missed appointments. The SSD stated it was not okay for residents to miss medical appointments due to lack of transportation. The DON stated her expectation was that Social Services arrange alternate transportation if the van was not available, and that missed pain management appointments did not meet her expectation because chronic pain needed to be treated effectively.
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.
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