Failure to Provide Chaperone Results in Missed Cardiology Appointment
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the resident's preferences. The resident, an elderly female with diagnoses including heart failure and cardiomegaly, was scheduled for a cardiology appointment for an echocardiogram. The resident required assistance with personal care and could not attend appointments alone. On the day of the appointment, transportation arrived as scheduled, and the resident was prepared and waiting in her wheelchair for her representative, who was supposed to escort her. Despite multiple attempts by the LVN to contact the resident's representative, the representative did not arrive on time. After waiting for 20 to 40 minutes and being unable to reach the representative, the LVN dismissed the ambulance and did not attempt to arrange for a staff member to accompany the resident, citing a lack of available staff. The incident was not reported to supervisors, and no further efforts were made to ensure the resident could attend the appointment. The resident ultimately missed the scheduled cardiology appointment. Interviews with facility leadership revealed that the expectation was for residents to be supported in attending medical appointments, and that the DON and ADON were not informed of the situation at the time. The facility's policy requires sufficient and qualified staff to meet residents' needs and to intervene in situations where neglect may occur. The failure to provide a chaperone or alternative support for the resident resulted in a missed medical appointment, contrary to the facility's stated procedures and expectations.