Failure to Arrange Transportation for Critical Follow-Up Appointments
Penalty
Summary
The facility failed to ensure that transportation was arranged for a resident’s scheduled follow-up oncology and nephrology appointments after discharge from the hospital and admission to the facility. The resident had Stage IV basal cell carcinoma with metastatic disease to the lung and bone, as well as Stage IV kidney disease. The hospital discharge summary included multiple diagnostic and physician appointments for a specific date, including a preclinical PET scan and visits with an oncologist and nephrologist, with times, departments, and locations clearly listed. A physician progress note documented that the resident’s family member informed the physician that an oncology follow-up was scheduled in about 10 days and asked whether transportation could be arranged. On the day of the scheduled appointments, the family member went to the oncology appointment expecting to meet the resident there, believing the facility had arranged transportation, but the resident did not arrive and all appointments were missed. Interviews and record review showed that the facility’s internal process for reviewing hospital discharge summaries and arranging transportation was not followed for this resident. The Transportation Nurse Aide stated that nursing staff are supposed to read the discharge summary for new admissions and then give it to her so she can identify and arrange transportation for any listed appointments. She reported that she never received this resident’s discharge summary, was not informed of the scheduled appointments, and therefore did not arrange transport, although she could have taken the resident if she had known. The Social Worker stated she was unaware of the missed appointments and that the Transportation Nurse Aide routinely checked discharge summaries and arranged transport, with the Social Worker assisting if the aide was absent. The DON confirmed that the Transportation Nurse Aide should have been given the discharge summary to arrange transportation but this did not occur, and the admitting nurse who might have provided further information was unavailable for interview due to a personal emergency.
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