Resident Sent to Methadone Clinic Without Required Escort Due to Communication and Staffing Failures
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment and a history of confusion was sent to a methadone clinic appointment without the required escort. The resident's medical record indicated diagnoses including encephalopathy, opioid abuse, and cancer, and the Minimum Data Set documented a BIMS score of 12/15, reflecting moderate cognitive impairment. Staff interviews confirmed that the resident was known to be forgetful, sometimes disoriented, and at risk of getting lost or harmed if left unsupervised in the community. Facility policy and a list of residents on methadone both specified that this resident required an escort for safety and to ensure the secure return of controlled substances. On the day of the appointment, the scheduled escort called out due to an emergency shortly before the resident's transportation arrived. The work clerk attempted to notify nursing staff that an escort was needed, but was unable to reach anyone by phone and ultimately learned the resident had already left without an escort. The LPN on duty, who was an agency nurse working his first shift at the facility, was not informed during shift handoff that the resident needed an escort and was unfamiliar with the facility's communication systems. The CNA who prepared the resident for the appointment also did not have information about the need for an escort. When the resident arrived at the clinic, a CNA supervisor who was not trained as an escort accompanied the resident but did not enter the clinic or participate in the appointment, as he was unsure of his responsibilities. The facility's policy required that, in the absence of a family member or representative, staff must escort residents with cognitive impairment or those receiving methadone to appointments. The lack of communication, inadequate handoff, and failure to ensure a trained escort resulted in the resident attending the appointment without appropriate supervision.