Failure to Provide Adequate Supervision During Resident Transportation
Penalty
Summary
Facility staff failed to ensure continuity of care and adequate supervision for a resident with dementia and mobility issues during transportation to a medical appointment. The resident, who had a history of memory problems, severe difficulty in daily decision-making, and required a wheelchair for mobility, was sent to a physician's appointment without an attendant or specific instructions provided to the transportation driver. The transportation request form indicated no attendant was needed, despite the resident's inability to self-transfer or ambulate safely. Upon arrival at the appointment location, the resident was dropped off at the back of the building while a family member was waiting at the front, resulting in the resident being left unsupervised. As a result of this lack of supervision and miscommunication, the resident fell, rolling down a hill and sustaining a head injury before being found by a construction worker. The facility's records and staff interviews confirmed that no instructions were given to the driver regarding the resident's needs, and there was no policy in place for making transportation arrangements or addressing accidents during transport. The resident was subsequently transported to the emergency department, where no traumatic injury was found, but the after-visit summary emphasized the need for the resident to be escorted into buildings for future appointments.