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F0745
D

Failure to Coordinate Transportation and Appointment Procedures Resulting in Missed Medical Appointments

Elmhurst, Illinois Survey Completed on 05-23-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to properly coordinate and document transportation and appointment procedures for residents requiring outside medical appointments, resulting in multiple missed or canceled appointments. One resident, who was cognitively intact, was unable to see her orthopedic physician because the necessary paperwork was not prepared, as the nurse was not notified of the appointment. This resident reported that this was not the first time appointments were missed due to lack of communication between the transportation coordinator and nursing staff. Review of the electronic medical record confirmed that appointment details were not entered, and the transportation coordinator admitted to not notifying the nurses or updating the resident's calendar in the EMR. Another resident reported missed doctor's appointments in the past due to the transportation coordinator's failure to arrange transportation. The transportation coordinator kept records of scheduled and canceled appointments on paper but did not document canceled appointments or resident refusals in the medical record. The resident's care plan and progress notes did not reflect any refusals or reasons for missed appointments, and the transportation coordinator was unable to provide clear reasons for the cancellations. A third resident, also cognitively intact, expressed concern about a canceled doctor's appointment, stating it was due to transportation issues and lack of an escort, which was the responsibility of the transportation coordinator. The transportation service had no record of the appointment being scheduled, and there was no documentation in the progress notes explaining the cancellation. Nursing staff confirmed that the resident was prepared for the appointment, but the absence of an escort and poor communication led to the cancellation. The facility's policy required timely scheduling and coordination of transportation and escorts, but these procedures were not consistently followed.

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