Failure to Supervise Cognitively Impaired Resident During Off-Site Appointment Transport
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and protection from accident hazards for a cognitively impaired resident during transport to an outside orthopedic appointment. The resident had diagnoses including a right femur neck fracture post-surgical repair, cognitive impairment following cerebrovascular disease, repeated falls, conversion disorder with seizures, osteoporosis, and chronic pain. The most recent MDS showed moderate cognitive impairment, wheelchair use, incontinence, and lower extremity impairment. Progress notes documented multiple recent falls, with root causes identified as poor safety awareness and confusion, and a physician note described the resident as confused and a poor historian. Hospital discharge orders included a follow-up orthopedic appointment, and the facility entered an appointment order; however, there were conflicting orders and a discontinued date that indicated a change in the appointment. On the day of the incident, the resident was transported by the facility’s transportation driver to the orthopedic office for what was believed to be a scheduled appointment. The orthopedic office reported that the resident arrived confused and agitated, without a current appointment, and that the office chart specified the resident should be accompanied by a caregiver. The driver left the resident at the office and went to get something to eat, did not confirm the appointment with the facility, and did not notify the facility when informed there was no appointment. The resident remained at the office unsupervised for approximately 2.5 hours until the facility was contacted and the resident was picked up. Facility staff, including the Unit Manager and Clinical Support Consultant, acknowledged a communication breakdown regarding the cancelled appointment, that the resident was not safe to be unsupervised due to periods of confusion, that transportation arrangements were not discussed at the initial care conference, and that the facility had no policy related to transportation or conduct for resident transport.
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