F0684

D

Failure to Supervise Incapacitated Resident During Off-Site Urology Appointments

Fairmont, West Virginia Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The facility failed to provide care and services in accordance with professional standards of practice by not ensuring supervision for an incapacitated resident during out-of-facility urology appointments. Record review showed that the resident had a Physician's Determination of Capacity form indicating incapacity and a care plan documenting dependence on staff for ADLs including bathing, grooming, dressing, eating, mobility, transfers, locomotion, and toileting due to limited mobility. A general patient note documented that during a prior urology visit, the resident became very upset, agitated, and destructive when required to wait, and the urology provider reported that the resident was not to come to appointments alone. Despite this, documentation showed that the resident had multiple subsequent urology appointments to which he was transported by the facility van.

Interviews further confirmed that the resident was left unsupervised at these appointments. The resident’s health care surrogate stated that facility staff leave the resident at appointments without anyone from the facility supervising him, particularly at the urology office, and that he is left sitting in the waiting room. The activity assistant/van driver reported that for residents without capacity, an aide typically accompanies them if family cannot come, but in this case, the driver took the resident inside the urology office and then waited in the van in the parking lot, noting that the resident’s son was supposed to come but was only present once or twice. A receptionist at the urology office stated that, during the time she had worked there, the resident was definitely alone in the waiting room on at least two occasions, that he did not talk, and that he sat there looking very sad.