Failure to Arrange Transportation for Outside PCP Appointments
Penalty
Summary
The facility failed to ensure transportation was arranged for a resident to attend all scheduled outside primary care physician (PCP) appointments as ordered. The resident was admitted with diagnoses including heart failure, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. A Minimum Data Set dated 7/18/2025 documented that the resident had severely impaired cognitive skills for daily decision making and was dependent in multiple activities of daily living, including eating, oral hygiene, toileting hygiene, bathing, lower body dressing, footwear, and personal hygiene, and required substantial/maximal assistance for transfers and ambulation. These conditions indicated the resident relied on staff for coordination of care and transportation to medical appointments. Family interview revealed that the resident had two outside PCP appointments scheduled on 8/4/2025 and 8/20/2025, and that no transportation was arranged by the facility for either appointment. The social worker stated that only one transportation arrangement had been made by the facility for an outside PCP appointment and explained that a physician order was required to arrange transportation, with licensed nurses responsible for placing the appointment order in the transportation communication binder. The social worker further stated she was unaware of the resident’s 8/20/2025 PCP appointment. Review of the Physician Orders Summary Report dated 7/16/2025 showed an order for a one-time outside appointment on 8/4/2025 at 11:00 AM, but there was no indication of an order for the PCP appointment on 8/20/2025.
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