F0684

D

Failure to Arrange Transportation for Specialist Appointments

Silvis, Illinois Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure residents received ordered specialist care when transportation was not arranged, resulting in missed pulmonology and neurology appointments. One resident with obstructive sleep apnea, congestive heart failure, and right lower lobe lung cancer had a scheduled pulmonology appointment documented on the facility’s calendar. Nursing progress notes show that on the day of the appointment the resident was prepared, a CNA had been arranged to accompany her, but no transportation arrived. Contracted transportation companies reported they did not have the resident scheduled for pickup, and the appointment had to be rescheduled. The LPN caring for the resident confirmed that the resident missed the pulmonology appointment solely due to transportation not being set up.

Another resident, admitted with high fall risk related to confusion, deconditioning, gait/balance problems, poor safety awareness, and a history of falls, had a neurology referral ordered by the nurse practitioner due to confusion. Documentation shows the referral paperwork was faxed, the family was notified and agreed with the plan, and a neurology appointment was scheduled and entered on the facility’s calendar. The resident’s family later reported that the resident missed neurology appointments because the facility could not get him to the appointments and that he was charged no-show fees. Nursing notes and staff interviews confirm at least one missed neurology appointment due to transportation not being set up and that the consult order remained outstanding after several days. The nurse practitioner also confirmed there were transportation issues that caused the resident to miss a needed neurology appointment, and that during the stay the resident experienced signs and symptoms of stroke and went to the emergency room.