Failure to Accompany Cognitively Impaired Resident to Cardiology Appointment
Penalty
Summary
The facility failed to provide appropriate treatment and care by not following its own policy for accompanying residents to outside medical appointments. The facility’s Transportation, Resident Appointments policy stated that a member of the nursing staff or Social Services would accompany a resident to an appointment when the resident could not go alone due to factors such as elopement risk, poor judgment, wandering behaviors, cognitive impairment, or need for assistance with ADLs. Resident R33’s clinical record showed diagnoses of dementia, Alzheimer’s disease, muscle weakness, and syncope, with a Minimum Data Set indicating ongoing cognitive impairment and dependence on staff for ADLs. A psychiatric evaluation further documented confusion, memory impairment, cognitive communication deficit, non-ambulatory status, muscle weakness, unsteady gait, and a history of falling. Despite these documented conditions that met the facility’s criteria for requiring staff accompaniment, the Appointment Calendar showed that Resident R33 was sent alone to a cardiology appointment on 1/28/26 at 7:30 a.m. A nurse progress note later recorded that staff from the cardiologist’s office reported the resident needed staff sent with her due to confusion and could not be seen. In an interview, the Director of Nursing confirmed that the resident was sent to the cardiology appointment without facility staff assistance and that the facility failed to provide needed care and services during the transfer to the outside appointment.
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