Failure to Arrange Timely Transportation for Post-Fracture Follow-Up
Penalty
Summary
A resident with dementia, chronic kidney disease, anemia, and a recent right distal humerus fracture was admitted to the facility and required a follow-up appointment with an orthopedic surgeon one week after discharge from the hospital. The hospital discharge summary specified the need for this timely follow-up to evaluate the resident's candidacy for open reduction surgery. However, the facility failed to ensure the resident was transported to the scheduled appointments due to repeated transportation issues, including the transportation company sending an inappropriate vehicle and late arrivals, resulting in multiple cancellations. Review of transportation request forms revealed that the facility did not specify the need for a wheelchair van, which contributed to the transportation problems. As a result, the resident experienced a delay of over a month before being evaluated by the orthopedic surgeon, contrary to the discharge instructions and medical needs. Interviews with facility staff confirmed ongoing transportation issues and acknowledged that the resident was not provided with the necessary services to attend critical follow-up appointments.