Resident Sent Unaccompanied to Cancelled Medical Appointment
Penalty
Summary
The facility failed to provide adequate supervision for a resident during an outside medical appointment. The resident, who had diagnoses including a gastrointestinal tumor, malignant neoplasm of the liver and bile duct, and COPD, but no dementia, was admitted with a care plan requiring supervised leave of absence. The care plan indicated that family would transport the resident for some appointments, but for the appointment in question, there was no documentation of who would accompany the resident. On the day of the appointment, the resident was transported by a third-party service without staff or family accompaniment. The facility was later notified by the medical office that the resident was waiting to be picked up, and it was discovered that the return trip had not been properly arranged, with the transportation service marking the return as 'will call.' The resident's daughter had cancelled the appointment but did not inform the facility, and the facility did not confirm the cancellation before sending the resident. The resident was left unattended at the medical office, became upset and hungry, and was eventually picked up by his daughter, who did not return him to the facility. Interviews confirmed that the resident was sent to the appointment unaccompanied, contrary to the care plan and usual facility practice. This incident affected one resident and was substantiated through record review, interviews, and self-reported incident investigation.