F0689

D

Failure to Provide Escort and Supervision for High-Risk Resident at Medical Appointment

Albuquerque, New Mexico Survey Completed on 02-09-2026

Penalty

No penalty information released

Summary

The facility failed to provide adequate supervision to prevent accidents when a resident with a history of falls and cognitive impairment was sent alone to a follow-up medical appointment. The resident had a history of cerebrovascular accident (CVA), poor safety awareness, and a tendency to move independently without using the call light or setting wheelchair brakes. The resident’s care plan, dated 09/27/25, included interventions such as more frequent visual rounding, offering frequent help as needed, and placing the resident in supervised areas when out of bed. Despite this, the resident was transported to a doctor’s appointment without an escort and was left unattended for an extended period.

The resident’s brother reported receiving a call from the doctor’s office asking who was supposed to pick the resident up and expressing concern for his safety, and he stated that the facility did not respond when he called to ask why the resident was left alone. The resident’s sister stated that due to his cognitive ability he could not be left alone, that the facility had assured her he would not be left alone, and that he was found sitting in a wheelchair with a paper and likely was not seen by the doctor because he was alone and unable to care for himself cognitively. The central supply/transport driver stated she was not aware the resident needed someone to go with him and explained that the process relied on the DON marking the appointment sheet if an escort was required; she also stated they had been trained that drivers do not stay at appointments and provide no patient care. An LPN stated that not every person going to an appointment has an escort and that the person scheduling appointments would know if an escort was needed, and she was not aware of this resident being left alone at his appointment.