Missed Echocardiogram Due to Unscheduled Transportation
Summary
The facility failed to ensure transportation was timely scheduled for a resident’s echocardiogram. The resident was admitted with diagnoses including type 2 diabetes mellitus, CHF, atrial fibrillation, HTN, CKD stage 3, and a cardiac pacemaker, and the quarterly MDS noted mild cognitive impairment. The care plan addressed impaired cardiovascular status and included an intervention for staff to ensure completion of ordered laboratory tests and diagnostic testing. A physician after-visit summary documented an echocardiogram order, and a later after-visit summary listed the echocardiogram appointment for 05/28/26 at 10:45 A.M.; the facility calendar also listed the appointment with the handwritten word “Transport” and a question mark above it. There was no documentation that the echocardiogram was completed on the scheduled date, and the procedure was not completed until 06/25/26. Nursing progress notes contained no documentation about the appointment, transportation arrangements, the missed appointment, or any rescheduling. During interviews, an RN stated no transportation had been set up for the appointment and the resident’s family member was upset. The resident stated she missed a cardiology appointment because the facility forgot to get transportation. The DON stated the floor nurse was responsible for entering the appointment order and arranging transportation, while another RN stated she scheduled the echocardiogram and wrote it on the calendar but did not set up transportation.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with multiple complex conditions, including CHF, DMII, morbid obesity, and chronic respiratory failure, who was cognitively intact but dependent on staff for several ADLs and used a wheelchair, was transported to the wrong location for a scheduled PET scan. Appointment documentation from a cardiology visit listed one testing site and time, while the physician order in the facility record listed a different site and date, resulting in the resident being taken to the incorrect testing center and missing the scan. The resident and spouse later contacted the facility from the wrong location and ultimately chose to walk back rather than wait for arranged transportation, contrary to the facility’s transportation policy that requires arranging and ensuring transport to and from outside appointments.
A resident with serious cardiac and vascular conditions was discharged from the hospital with an order for cardiology follow-up within 1 to 2 weeks, but the appointment was not entered into the EHR or scheduled. The SSD, MDS Manager, Case Manager, and DON each confirmed the appointment should have been ordered and coordinated, and the facility policy required assistance with scheduling, transportation, and documentation of medically necessary appointments.
A resident with recent bilateral lower extremity amputations missed a scheduled post-surgical physician appointment because the facility did not provide necessary transportation and Spanish interpretation support. Staff were unable to coordinate a Spanish-speaking staff member or family member to accompany the resident, resulting in a delay in follow-up care for surgical wounds.
A resident with hemiplegia/hemiparesis after an intracerebral hemorrhage and polyneuropathy missed a long-awaited neurology appointment because CNA prep was delayed. The resident and family were upset, stating the resident was not ready when the transport driver arrived, the mechanical lift was not nearby, and staff communication was poor. The CNA said the resident initially refused to get ready but did not document it or notify the CN, while the SSD confirmed the appointment had been scheduled for months and the delay could affect care.
A resident with epilepsy and schizophrenia was supposed to have a brain MRI ordered by Neurology, but the facility failed to ensure transportation was arranged and the appointment was missed or delayed multiple times. Staff and family reported confusion about pickup times, no clear record of transportation requests, and the resident said an escort was needed for appointments. Nursing and NP notes documented that transportation did not arrive or the resident did not get downstairs in time, and staff acknowledged the resident should have had the MRI sooner.
A resident did not receive assistance from the facility in arranging transportation to and from radiology services, leading to missed or uncoordinated appointments.
Failure to Provide Accurate Transportation for Outside PET Scan Appointment
Penalty
Summary
The facility failed to ensure adequate transportation was provided for an outside radiology appointment for Resident #96. The resident, admitted on 10/03/24, had diagnoses including acute chronic systolic heart failure, type II diabetes mellitus, morbid obesity, chronic respiratory failure, and major depression bipolar disorder. An MDS assessment dated [DATE] showed she was cognitively intact but dependent on staff for toileting, bathing, footwear, and turning in bed, and she used a wheelchair for mobility. Nursing progress notes confirmed multiple outside appointments, including a PET scan scheduled for 04/03/25. The after-visit summary from a cardiology appointment on 04/03/25 documented a PET scan scheduled at a testing location in Columbus, Ohio at 2:00 P.M., but the physician order in the medical record listed the PET scan for 04/16/25 at a different testing location in [NAME], Ohio at 1:30 P.M. A concern form completed by the Administrator documented that on 04/03/25 the resident was taken to the wrong testing center for the PET scan, causing the test to be missed and requiring rescheduling. A written statement by the Administrator dated 04/16/25 confirmed a transportation mistake was made for the 04/03/25 appointment and that the resident and her spouse contacted the facility to arrange pick-up from the incorrect location. During an interview, the Administrator confirmed the resident was taken to the wrong location and that Administrator Assistant #596 worked with the resident to ensure her return to the facility, but the resident and her spouse did not wait for transportation and decided to walk back to the facility. Review of the facility’s Transportation policy dated 08/24 showed the facility was responsible for arranging and ensuring transportation to and from outside appointments based on information received from the resident, family, transportation company, or doctor’s office. This failure affected one of three residents reviewed for transportation to outside appointments, with a facility census of 80, and was investigated under Complaint Numbers 2572222, 1376015 (OH00165472), and 1376014 (OH00165055).
Failure to Schedule Ordered Cardiology Follow-Up
Penalty
Summary
The facility failed to ensure a cardiology appointment was scheduled within 1 to 2 weeks after hospitalization for a resident with significant cardiac and vascular diagnoses, including circulatory disorder, embolism and thrombosis of the lower extremity arteries, cardiomyopathy, acute on chronic combined systolic and diastolic congestive heart failure, and hypertensive heart disease with heart failure. The resident’s hospital discharge summary indicated a follow-up with cardiology within 1 to 2 weeks and directed staff to call for an outpatient follow-up appointment for further management of cardiomyopathy and heart failure. During interview and record review, the resident stated the cardiology appointment had not yet been scheduled. The SSD stated the case manager, MDS Manager, nurses, and ADON could be involved in scheduling, and Social Services arranged transportation. The MDS Manager confirmed the cardiology appointment was not in the active order list in the EHR, and the Case Manager stated the appointment should have been ordered upon admission or shortly after. The DON confirmed the admitting nurse did not see the appointment and failed to input the order in the EHR, and that the appointment should have been discussed with the physician and the resident. The facility policy stated it would assist with scheduling, transportation, and coordination of medically necessary appointments, and that appointments would be documented in the resident record.
Missed Post-Surgical Appointment Due to Lack of Transportation and Interpreter Coordination
Penalty
Summary
The facility failed to ensure that a resident with bilateral below-the-knee amputations received necessary assistance with transportation and interpretation services to attend a scheduled post-surgical physician appointment. The resident, who had recently undergone amputation and required follow-up care for surgical wounds, missed her appointment because no staff member was available to accompany her and provide Spanish interpretation, as required for her to communicate effectively during the visit. The facility attempted to contact the resident's family to provide interpretation, but the responsible party was unable to assist due to language barriers. Interviews with facility staff revealed that the process for arranging transportation and interpretation was not effectively coordinated. The receptionist received the order to schedule the appointment and was informed of the need for a Spanish-speaking staff member to accompany the resident. However, due to staffing shortages on the day of the appointment, no staff member was available to go with the resident. The nursing and administrative staff indicated that they expected either a staff member or a family member to accompany the resident, but this was not arranged in time for the appointment. The facility's policy on language access states that individuals with limited English proficiency must have meaningful access to services, and that family members should not be relied upon for interpretation unless explicitly requested by the resident. Despite this, the facility's actions did not ensure that the resident had access to interpretation services for her medical appointment, resulting in the missed appointment and a delay in post-surgical care.
Missed Neurology Appointment Due to Delayed Transport Preparation
Penalty
Summary
The facility failed to have 1 of 32 sampled residents, Resident 48, ready in time for a neurology appointment. Resident 48 was admitted with diagnoses including hemiplegia and hemiparesis following a nontraumatic intracerebral hemorrhage and polyneuropathy. On 8/28/25, Resident 48 and his family member were visibly upset after he missed his first appointment with a neurologist, which he had been waiting over 4 months to attend. Resident 48 stated he was over 20 minutes late because CNA 6 did not get him ready on time, and he reported frustration with the lack of communication between staff and the mechanical lift not being nearby when needed. The transportation driver stated he was outside the resident’s room at the scheduled 1:30 PM pick-up time, but the resident was not ready. CNA 6 confirmed she was assigned to Resident 48 and stated it usually took about 45 minutes to transfer him because of his preferred leg positioning with the mechanical lift. CNA 6 stated Resident 48 initially refused to get ready when asked just after noon, but she did not document the refusal, inform the charge nurse, or ask for assistance. CNA 6 also confirmed she had to ask CNA 9 to find a mechanical lift. Resident 48 and his family member stated the family member arrived early so the resident could receive pain medication before transfer, and both said he never refused to get ready for the appointment. The Social Services Director confirmed the appointment had been scheduled since April 2025 and stated the missed appointment could delay the resident’s care. The Transportation Sign In/Out Log showed the driver arrived at 1:30 PM and the resident left the facility at 2:20 PM.
Missed MRI Transportation Arrangements
Penalty
Summary
The facility failed to ensure that Resident #8 was assisted with transportation arrangements for a brain MRI ordered by Neurology. Resident #8 was admitted with diagnoses including paranoid schizophrenia and epilepsy, and the most recent MDS indicated intact cognition with a BIMS score of 15 out of 15. The Neurology consultation documented evaluation for seizures and sensory impairment and included a plan to send the resident for an MRI brain for evaluation of parkinsonism. Records showed repeated missed or delayed MRI appointments tied to transportation problems. A nursing note documented that the resident returned from the Neurology appointment with no new orders, while later nursing and nurse practitioner notes stated the MRI was scheduled but transportation did not arrive, the appointment was rescheduled, and follow-up still needed to be arranged. The resident told the surveyor that he/she had been told the appointment was at 2:00 P.M. but later learned the transport company had a 1:30 P.M. pickup time, resulting in a missed ride. The resident also stated a desire for an escort to appointments, and the family member said they had not heard anything from the facility about the appointment and believed an escort was necessary. Facility staff gave conflicting information about transportation and escort arrangements. The Unit Manager stated the facility books transportation and may send a staff escort if a family member does not accompany the resident, and said the resident should have an escort because the appointment would be too much for him/her. The Unit Secretary and ADON said the facility was responsible for ensuring the resident got to appointments, but review of the transportation companies found no record of transportation requests for the resident. The appointment binder and nursing notes showed multiple MRI dates and rescheduling attempts, including a note that transportation came for one appointment but the resident never came downstairs and left, and staff later acknowledged the resident should have had the MRI sooner.
Failure to Assist with Transportation for Radiology Services
Penalty
Summary
A deficiency was identified when the facility failed to assist a resident in making transportation arrangements to and from radiology services. The report notes that the necessary support for coordinating transportation was not provided, resulting in the resident not having appropriate means to attend scheduled radiology appointments.
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