Failure to Escort Cognitively Impaired Resident to Outside Medical Appointment
Penalty
Summary
The facility failed to provide appropriate supervision and support for a cognitively impaired resident during an outside medical appointment. The resident, admitted with diagnoses including prostate cancer and neuromuscular bladder, had a minimum data set assessment identifying moderate cognitive impairment. There was no facility documentation of the resident going out to an appointment on 12/31/25. Despite this cognitive status, the resident was sent alone to a Veterans Affairs (VA) appointment without an escort or spokesperson. VA staff, including a social worker and RN, reported that the resident arrived unaccompanied, was oriented only to name, did not know why he was there, and was unable to participate in conversation or answer questions beyond his name. Interviews with facility staff, including unit managers, the DON, and the Administrator, confirmed that the resident had limited cognition, that the facility normally sent escorts with cognitively impaired residents, and that no escort accompanied this resident to the appointment. Facility staff also stated they did not maintain a record of assigned escorts for past appointments. VA documentation, including a physician note and social worker note, identified the resident as having a history of dementia and described the appointment as ineffective due to the resident’s inability to exchange substantial information. The Administrator verified that the resident was sent to the appointment with limited cognition and no escort, resulting in the cited deficiency.
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