F0689

D

Failure to Provide Escort and Adequate Supervision for Cognitively Impaired Resident at Off-Site Clinic Visit

Houston, Texas Survey Completed on 01-14-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure a resident’s environment remained as free of accident hazards as possible and that the resident received adequate supervision and assistance devices to prevent accidents during an off-site clinic visit. The resident was an elderly male with multiple significant diagnoses, including unspecified dementia with agitation, hypertension, dysphagia, left-sided hemiplegia and hemiparesis following a cerebral infarction, depression, HIV disease, cognitive communication deficit, and blindness in one eye. His Annual MDS showed he was rarely or never understood, had short- and long-term memory problems, was severely impaired in daily decision-making, and required total assistance for toileting, showering, footwear, and bed mobility. His care plan documented an ADL self-care performance deficit requiring a mechanical lift with two staff for transfers, impaired cognitive function/dementia requiring cueing, reorientation, and supervision, and a seizure disorder with specific post-seizure interventions.

On the date of the clinic visit, there was no documentation in the resident’s medical record regarding the off-site appointment, including in progress notes, assessments, or uploads. At the clinic, the NP who saw the resident reported that he arrived not responsive, not oriented, and unaccompanied. The NP stated the resident was only able to answer a little, and another NP had to call the resident’s responsible party (RP) because the resident could not provide necessary information. The NP also reported the resident was soiled upon arrival, and clinic medical assistants were unable to assist him into a standing position to change him. Clinic staff confirmed the appointment date and reported that the resident did not have his health information with him when he arrived.

The resident’s RP stated she was aware of the appointment but was not told by the facility that she needed to attend with the resident; she reported the facility told her they would get him to the appointment. She further stated the clinic called her during the visit because the resident could not recite his birthday and social security number and that the clinic told her they tried to call the facility but were unable to reach anyone. Facility staff interviews showed inconsistent understanding and lack of clear responsibility for arranging an escort: an LVN recalled seeing the resident leave for the appointment and assumed the RP would be there; the SW stated the facility typically sent someone with this resident and that he should have been accompanied, but she acknowledged she had forgotten to enter the escort information in the record, describing this as an oversight. The Administrator and MDS nurse both acknowledged that some residents required escorts and that this resident, with a BIMS of 0 and being rarely or never understood, should have been accompanied, yet there was no policy in place on accompanying residents to appointments and no documentation of an escort for this visit. A requested supervision policy and documentation of the resident’s 12/31 appointment notes were not provided by the time of survey exit.

Interviews with leadership further confirmed that there was no specific written policy on escorts to off-site appointments and that the process relied on communication among staff and with the RP. The Administrator stated that some residents could go alone and some had an aide, and that if residents needed an escort, the facility would coordinate it, sometimes based on family-made appointments and BIMS scores. The MDS nurse reported that an aide was supposed to go with the resident but did not know who, and she did not believe escort needs had to be care-planned because staff were presumed to know which residents required escorts. The DON stated that if the resident was going to a clinic, he would have been supervised by the van driver and clinic staff, indicating reliance on external personnel rather than a designated facility escort. Overall, the resident, who had severe cognitive and functional impairments and was dependent on staff for mobility and ADLs, was sent to an off-site clinic visit without an escort, without his health information, and without facility documentation of the visit, constituting the cited failure to ensure adequate supervision and a hazard-free environment during the off-site appointment.