Resident Sent Unsupervised to Medical Appointment
Penalty
Summary
A deficiency occurred when a resident with significant medical and cognitive impairments, including traumatic brain injury, quadriplegia, dementia, and a history of falls, was sent alone to an outside medical appointment. The resident required a two-person assist for transfers, used a Hoyer lift, and typically utilized a Geri chair when up. Despite these needs and the usual practice of a family member accompanying the resident to appointments, staff failed to ensure supervision during the appointment. Both family members and staff interviews confirmed that the family was not informed of the appointment and that staff assumed the family would meet the resident at the appointment location. Record reviews and staff interviews revealed that there was no facility policy regarding supervision during medical appointments, and staff relied on assumptions rather than confirmation of arrangements. The transportation company confirmed that the resident traveled alone to the appointment. Facility leadership acknowledged that the resident should not have been left unsupervised and that there was a lack of follow-up to ensure appropriate supervision was provided.