Resident Mistakenly Sent to Unscheduled Medical Appointment Due to Failure in Appointment Verification
Penalty
Summary
The facility failed to ensure compliance with its policies and procedures regarding resident appointment coordination and verification, resulting in a resident being mistakenly prepared and transported to a medical appointment that was not scheduled for her. The resident, who had a history of fractures to the cervical vertebrae and pelvis, osteoporosis, and moderate cognitive impairment due to dementia, was admitted following a fall at home. The resident's family member was not informed of any scheduled appointment at a cancer treatment center and confirmed that the resident did not have a cancer diagnosis or require cancer treatment. On the day of the incident, the facility's Order List Report did not list the resident as having a scheduled appointment, but two other residents, including the resident's roommate, were scheduled. The ward clerk, responsible for tracking and communicating appointments, did not indicate that the resident had an appointment, and the nursing staff failed to verify the appointment list. The nursing staff prepared the resident for transport based on incorrect information and did not follow the required procedure of verifying the resident's face sheet, doctor's orders, and appointment location before sending her out. The error was discovered when the cancer clinic identified that the wrong resident had been sent, prompting the facility to arrange transport for the correct resident. Interviews with the DON, ward clerk, and LVN confirmed that staff did not follow established procedures for verifying and preparing residents for appointments, leading to the resident experiencing unnecessary physical and emotional distress.