Resident Identification Failure Leads to Missed Medical Appointment
Penalty
Summary
The facility failed to ensure accurate resident identification prior to transporting a resident for an outside medical appointment, resulting in the wrong resident being sent to a scheduled surgical appointment. Specifically, a resident with diagnoses including hemiplegia, hemiparesis following cerebral infarction, heart failure, and moderate recurrent major depressive disorder, who also had moderate cognitive impairment, did not attend his scheduled cataract surgery. Instead, another resident was mistakenly transported in his place. The error occurred when the driver, who had only been in the role for a few weeks, relied on a CNA's verbal confirmation rather than verifying the resident's identity using the face sheet or checking with the floor nurse as required by facility protocol. Interviews revealed that the driver did not follow the established process of bringing the face sheet to the resident's room and confirming the resident's identity through the electronic health record (PCC) and with nursing staff. The driver admitted to not reviewing the face sheet and instead asked a CNA in the hallway to identify the resident, leading to the mix-up. The facility did not have a written policy outlining the steps for verifying resident identity before transport to outside appointments, contributing to the deficiency.