Resident Left Unattended at Off-Site Appointment Due to Scheduling and Supervision Failures
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including dementia, schizophrenia, osteoporosis, impaired balance, and a moderate level of cognitive impairment, was left unattended at an off-site medical appointment. The resident was transported by a facility van driver to a hospital for a scheduled appointment that had actually been canceled. The driver, after confirming details with an overnight nurse but receiving no special instructions, dropped the resident off at the hospital and left, without ensuring appropriate supervision or arrangements for the resident's return. The resident was found unsupervised outside in a hospital courtyard by a security guard, who then notified hospital staff and the facility. The resident's care plan indicated a need for supervision during ambulation with a walker due to physical mobility needs, but the resident was sent to the appointment without her required assistive device. The facility's appointment scheduling process failed when the scheduler did not update the appointment book or notify the van driver of the cancellation, despite being informed by the MDS coordinator and the resident's guardian that the appointment was no longer needed. As a result, the resident was left alone in an unfamiliar environment, with diminished cognition and altered physical ability, and without the necessary mobility support. Interviews with facility staff, including the DON and Administrator, confirmed that the facility's protocol required staff to accompany residents to off-site appointments when supervision was indicated, and that this protocol was not followed in this instance. The incident was documented in the facility's incident report, and the failure to provide adequate supervision and assistance devices as required by the resident's care plan led to the identification of an Immediate Jeopardy situation.