Resident with Dementia Sent Unsupervised to Incorrect Medical Appointment
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a diagnosis of dementia was mistakenly sent, unsupervised, to a medical appointment that was actually scheduled for another resident. The resident required maximal assistance with several activities of daily living and was not capable of safely attending appointments alone. The error originated when the Social Service Director (SSD) entered an orthopedic appointment and transportation order for the wrong resident, due to confusion caused by multiple residents sharing the same first name. This resulted in the resident being transported eleven miles away from the facility without proper supervision or notification to the responsible party. Facility staff, including a Licensed Vocational Nurse (LVN), were unaware of the resident's cognitive status and did not verify the appropriateness of the appointment or the need for supervision. The LVN prepared the resident for the appointment based on the facility's appointment calendar and handed the resident an envelope for the doctor, without confirming with the responsible party or ensuring the resident's safety. The responsible party only became aware of the situation after receiving a notification from the transportation company and subsequently alerted the facility, which was not initially aware that the resident had left the premises. Interviews with staff revealed a lack of communication and verification processes regarding off-site appointments for residents with cognitive impairments. The facility's policy required continuity of care during leaves of absence, but this was not followed in this instance. The resident, who was unable to recall details of the event due to her dementia, expressed feelings of anxiety and fear during the unsupervised trip. The incident highlighted failures in resident identification, staff awareness of resident needs, and adherence to established procedures for resident safety during off-site appointments.