Failure to Provide Supervision During Resident Transportation
Penalty
Summary
A deficiency occurred when a resident with diagnoses including dementia, convulsions, and blindness in one eye, and who was assessed as having moderately impaired cognition and lacking capacity to make reasoned medical decisions, was sent unaccompanied to multiple medical appointments. The resident's clinical record indicated a need for 24-hour care and supervision, and a physician's statement confirmed the resident's inability to provide informed consent or medical history. Despite these documented needs, the resident was transported alone to appointments, and on at least one occasion was left in the lobby of a doctor's office without a caretaker from the facility. Interviews with facility staff revealed inconsistent practices and a lack of clear procedures regarding which residents required staff accompaniment to appointments. The unit clerk stated that, until recently, staff did not accompany residents, and decisions about competency were made informally. The DON acknowledged that the resident should not have been allowed to leave the facility alone, and the administrator recognized the concern regarding the resident's care plan for 24-hour supervision not being followed during transportation to appointments.