Failure to Ensure Timely and Appropriate Transportation for Medical Appointments
Penalty
Summary
The facility failed to adequately assist residents in arranging and coordinating transportation to and from medical appointments, resulting in missed or delayed appointments for three residents. One resident, who had a history of end stage renal disease and diabetes, experienced repeated issues with a specific transportation company, leading to missed appointments and the need to reschedule. The resident's preference for a different transportation provider was not accommodated, and when concerns were raised with the Social Services Designee (SSD), the resident was advised to contact their insurance rather than receiving direct assistance from the facility. Documentation showed that the resident was cognitively intact and had clearly communicated her transportation preferences and frustrations. Another resident, with a history of hemiplegia, cerebral edema, and mental health disorders, missed appointments due to transportation problems, including a vehicle with a flat tire and a van that could not accommodate his specialized wheelchair. The resident's responsible party reported poor communication from the facility regarding missed and rescheduled appointments, and there was no documentation of these communications in the resident's chart. The SSD confirmed that transportation issues had occurred and that communication with responsible parties was not consistently documented. A third resident, who was cognitively intact and had diagnoses including Alzheimer's disease and congestive heart failure, was left waiting for hours after a medical appointment because the scheduled transportation did not arrive. The resident ultimately had to arrange alternative transportation, resulting in significant distress. Facility staff interviews and record reviews revealed that the process for monitoring residents' departures and returns from appointments was inconsistent, with incomplete logs and unclear responsibilities among staff. The Director of Nursing and Administrator acknowledged gaps in communication, documentation, and staff training related to transportation arrangements and resident safety during off-site appointments.