Failure to Assess Resident's Appropriateness for Unaccompanied Transfer to Medical Appointment
Penalty
Summary
The facility failed to properly assess whether a resident was appropriate for lone transfer to an outside medical appointment, as required by professional standards of care. The resident in question had a history of functional quadriplegia, chronic pain syndrome, morbid obesity, mobility deficits, and moderate cognitive impairment, as evidenced by a BIMS score of 10 out of 15. Therapy notes indicated the resident was dependent for mobility and self-care, rarely got out of bed, and frequently refused therapy. Despite these factors, the resident was sent alone via a contracted medical transportation company to a dermatology appointment, seated in a standard large facility wheelchair. Upon arrival at the appointment, the resident was found sliding out of the wheelchair, with wet feet and only socks on, and was unable to reposition themselves. It required four people to assist the resident back into the wheelchair, but the resident continued to slide out and cried out in pain. The dermatologist's office refused to see the resident, and EMS was contacted to transport the resident back to the facility. There was no progress note in the medical record documenting the resident's status or the fact that they left the facility for the appointment on the day of the incident. Interviews with facility staff and the resident's representative revealed that the resident rarely, if ever, got out of bed or used a wheelchair for any length of time, and staff expressed uncertainty about the resident's ability to safely use a wheelchair or understand how to reposition themselves. The facility's own policy required assessment of the need for accompaniment to outside appointments based on cognitive and physical status, but this was not followed. The resident's representative was not notified of the appointment or transportation arrangements, and only learned of the incident after being contacted by the emergency department.