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F0774
D

Failure to Arrange Appropriate Transportation Resulting in Missed Medical Appointments

Los Angeles, California Survey Completed on 07-28-2025

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 ensure proper transportation arrangements for a resident with significant mobility and medical needs, resulting in missed doctor's appointments and blood work. The resident, who had diagnoses including acute embolism and thrombosis, peripheral vascular disease, schizophrenia, and HIV, required either a bariatric van, gurney, or geriatric chair for safe transport. Documentation showed that the resident was dependent on staff for transfers and required maximal assistance for mobility. On multiple occasions, the facility arranged transportation that did not meet the resident's needs, such as sending a non-bariatric van or a non-gurney vehicle, leading to the cancellation of scheduled medical appointments. Interviews with the resident and multiple staff members, including an LVN, Social Services director, Director of Staffing Development, and DON, confirmed that the resident missed at least two doctor's appointments and associated blood work due to inappropriate transportation being provided. Staff acknowledged awareness of the resident's specific transport requirements and the repeated issue of the transportation company sending vehicles that could not accommodate these needs. The facility's policy indicated that social services would assist residents in obtaining transportation, but this was not effectively implemented for this resident, resulting in the deficiency.

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