Citations in Wisconsin
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Wisconsin.
Statistics for Wisconsin (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Wisconsin
Surveyors identified multiple deficiencies in food service sanitation, including staff not using proper hair restraints, unclean kitchen equipment, personal beverages on food prep counters, improper storage of food under freezer drips, and opened food items without required dating. These failures affected all residents, as they occurred in areas where food for the entire facility is prepared and stored.
The facility did not have an infection prevention and control program in place, as observed and documented by surveyors.
Two residents voiced grievances regarding lack of assistance with mobility and dissatisfaction with wound care, but the facility did not follow its grievance policy to investigate, document, or resolve these concerns. Staff acknowledged the complaints but failed to initiate the required grievance process or communicate outcomes to the residents.
A resident with a history of chronic kidney disease, diabetes, and urge incontinence was treated for an acute urinary tract infection with ciprofloxacin without a culture and sensitivity test to confirm the antibiotic's effectiveness. Facility policy requires such testing and review by the Infection Preventionist, but documentation was lacking, and leadership confirmed the omission during the survey.
A resident with a history of stroke, hemiplegia, and moderate cognitive impairment was found with unexplained swelling and bruising, later requiring hospitalization for a hematoma and pneumothorax. Facility staff did not conduct a risk management investigation or report the injury of unknown origin to the NHA or State Agency, contrary to policy and regulatory requirements.
A resident with multiple chronic conditions indicated a preference to receive the RSV vaccine by signing the appropriate consent form, but the vaccine was not administered. The Infection Preventionist confirmed the vaccine was not given and stated it would have required ordering from the pharmacy, acknowledging the resident should have received it as requested.
Two residents did not receive care planned interventions to prevent accidents and falls. One resident, requiring two-person assist and proper use of an EZ stand lift, was transferred by a CNA without fastening the safety strap and without a second staff member, resulting in a fall to the floor. Another resident, assessed as a fall risk and requiring gripper socks at all times, was observed wearing regular socks, and staff were unaware of his care plan requirements. Facility staff did not follow care plans or manufacturer instructions, leading to deficiencies in accident prevention.
Two residents did not have current advance directives or documentation of advance care planning in their records, and there was no evidence that they were offered assistance or that their preferences were documented, despite facility policy requiring this. The Social Services Director confirmed the absence of required documentation and follow-up.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. The environment lacked proper hazard controls and sufficient monitoring, increasing the risk of accidents for residents.
A resident with moderate cognitive impairment and a history of wandering left the facility without staff authorization after independently arranging transportation. Although the care plan noted the guardian's permission for the resident to leave for smoking, no new interventions or monitoring were added following the incident, despite facility policy requiring updates to care provision after such events.
Failure to Maintain Sanitary Food Service Environment and Practices
Penalty
Summary
Surveyors observed multiple failures in maintaining a safe and sanitary environment in the facility's food service operations. Staff in the food preparation area were seen without proper hair restraints, including one staff member wearing a personal baseball cap and another with a stocking cap not designated for kitchen use. The facility's policy requires clean, designated hair restraints, but staff were unclear on laundering frequency and whether hats were used outside the facility. Additionally, a mixer was found stored with visible food residue inside, indicating it had not been cleaned before storage. Staff were also observed with personal beverages on food preparation counters, contrary to facility policy prohibiting eating and drinking in these areas. Further deficiencies included improper food storage practices. Surveyors found frozen drips on the ceiling of the walk-in freezer, with opened and unsealed boxes of vegetables stored underneath, resulting in ice buildup on and inside the boxes. Opened containers of juice in the juice machine were undated, and staff were unable to confirm when they had been opened. Facility policy requires all opened food and beverages to be labeled with an open or use-by date, but this was not followed. These observations affected all 47 residents in the facility, as the issues were present in areas where food for all residents is prepared and stored.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, as the facility did not have an established or operational program to prevent and control infections among residents and staff. The absence of such a program was directly observed and documented by surveyors.
Failure to Investigate and Resolve Resident Grievances per Facility Policy
Penalty
Summary
The facility failed to honor residents' rights to voice grievances without discrimination or reprisal, and did not follow its own grievance policy for two residents. The policy requires prompt investigation, documentation, and resolution of grievances, overseen by a designated Grievance Official. In both cases, the facility did not document a thorough investigation or resolve the grievances as outlined in their procedures. One resident, who had moderate cognitive impairment and multiple mobility-related diagnoses, expressed concerns about not receiving assistance when moving from the dining room to his room. Progress notes indicated that the resident was upset about not being helped and voiced his intention to report the issue. Staff interviews revealed that the concern was not reported as a grievance, and the required documentation and investigation were not completed. The staff acknowledged that the resident frequently expressed such concerns, but no formal grievance process was initiated in response to his repeated complaints. Another resident with a history of diabetic foot ulcers voiced a grievance about wound care, specifically not wanting a particular nurse practitioner to debride her wound due to increased pain. The resident reported her concerns to both the Nursing Home Administrator and a nurse. Although an administrative assistant recognized the concern as a grievance and reported it to the administrator, no grievance form was completed and the facility did not follow up according to its policy. In both cases, the facility did not adhere to its established grievance procedures, failing to ensure prompt investigation, documentation, and communication with the residents involved.
Failure to Follow Antibiotic Stewardship Protocols for UTI Treatment
Penalty
Summary
The facility failed to follow its own standards of practice for antibiotic stewardship by not ensuring that a culture and sensitivity test was performed before prescribing antibiotics for a resident diagnosed with an acute urinary tract infection. The resident, who had a medical history including chronic kidney disease, Type 2 diabetes mellitus, and urge incontinence, experienced symptoms such as pain, itching, and burning in the vaginal area. After being seen in the emergency department, the resident was diagnosed with a urinary tract infection and prescribed ciprofloxacin without evidence of susceptibility testing to confirm the appropriateness of the antibiotic. Facility policy requires that antibiotic use be based on clinical standards, including evaluation of symptoms and, when necessary, obtaining further documentation to support the treatment plan. The Infection Preventionist or designee is responsible for reviewing antibiotic orders, which includes ensuring the necessity and appropriateness of the treatment. During the survey, the Vice President of Clinical Operations confirmed that there was no culture and sensitivity test documented in the resident's electronic health record, acknowledging that such testing should have been completed to ensure the correct antibiotic was prescribed.
Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that all alleged violations involving injuries of unknown origin were reported immediately to the administrator and the State Agency, as required by both facility policy and state law. A resident with a history of cerebral infarction, hemiplegia, difficulty walking, and moderate cognitive impairment was found to have swelling on the right hip and dark purple bruising on the right shoulder and arm. The origin of these injuries was unknown, and the resident was subsequently hospitalized with a hematoma and pneumothorax requiring a chest tube. Despite the facility's policy mandating immediate reporting and investigation of such injuries, there was no documentation of a risk management investigation or notification to the Nursing Home Administrator or State Agency. Interviews with facility staff, including a Registered Nurse/Nurse Manager and the Director of Nursing, confirmed that the expected procedure would have included an assessment, provider notification, investigation, and documentation in risk management. Both staff members acknowledged that this process did not occur for the resident in question. The Nursing Home Administrator also confirmed that the injuries should have been classified as of unknown origin and reported accordingly, but this was not done.
Failure to Administer RSV Vaccine per Resident Preference
Penalty
Summary
A deficiency occurred when the facility failed to honor a resident's right to participate in and make informed decisions about her treatment. The resident, who had a medical history including multiple sclerosis, pneumonitis, and a personal history of Covid-19, was offered the Respiratory Syncytial Virus (RSV) vaccine. She indicated her preference to receive the vaccine by checking 'Yes' and signing the Acknowledgement of Receipt of Vaccine Information Sheet. Despite this documented preference, there was no evidence in her electronic health record that the RSV vaccine was administered. During an interview, the facility's Infection Preventionist confirmed that the resident did not receive the RSV vaccine and explained that the facility would have needed to contact the pharmacy to obtain it, as it was not stocked in-house. The Infection Preventionist also acknowledged that the resident should have received the vaccine according to her expressed wishes. This failure to provide the vaccine as requested was not in accordance with the facility's policies on resident rights and self-determination.
Failure to Provide Adequate Supervision and Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that residents received adequate supervision and assistive devices to prevent accidents, as evidenced by two residents who did not have their care planned interventions implemented. One resident, who was assessed and care planned for two-person assistance with an EZ stand lift for transfers, was transferred by a CNA who did not follow the manufacturer’s instructions. The safety strap on the harness was not fastened around the resident’s waist, and the transfer was attempted with only one staff member present. During the transfer, the resident began to slide through the straps and was lowered to the floor, resulting in a change in plane and reported shoulder pain. Multiple staff interviews confirmed that the safety strap was not used as required, and that the resident was not transferred according to her care plan, which specified two-person assistance. Another resident, who had a history of repeated falls and was assessed as a fall risk, was observed without his care planned fall prevention intervention in place. The resident’s care plan and Kardex specified that he should wear gripper socks at all times and not wear shoes due to a wound on his toe. However, the resident was observed in the dining room wearing regular socks, and a CNA admitted to attempting to put shoes on the resident, contrary to the care plan. The resident confirmed that his shoes caused a wound on his toe, and the CNA only provided gripper socks after the surveyor’s intervention. Staff interviews revealed a lack of awareness regarding the resident’s fall risk status and the required interventions. Facility policies required that residents be handled and transferred safely according to their individual care plans and that mechanical lifts be used according to manufacturer instructions. The policies also mandated that fall prevention interventions be implemented and monitored for effectiveness. In both cases, staff failed to follow established care plans and manufacturer guidelines, resulting in residents not receiving the necessary supervision and interventions to prevent accidents and falls.
Failure to Document and Facilitate Advance Directives for Two Residents
Penalty
Summary
The facility failed to ensure that two residents' rights to request, refuse, and/or discontinue treatment and to formulate an advance directive were honored, as required by facility policy. For both residents, their charts did not contain current copies of their advance directives or documentation of advanced care planning beyond code status. During record reviews, surveyors were unable to locate copies of the residents' advance directives or Power of Attorney for Health Care (POAHC) in the electronic medical records. Interviews with the Social Services Director confirmed that there was no documentation on file for either resident regarding their advance directives or evidence that assistance was offered or preferences were documented. In one case, documentation indicated that a resident was interested in completing advance directive documents, but there was no evidence that assistance was provided or that this interest was followed up on. The Social Services Director acknowledged that documentation should have been present to show that residents were offered assistance in completing advance directives and that their preferences were recorded. The lack of documentation and follow-up regarding advance care planning for these residents constituted a failure to comply with the facility's own policy and federal requirements.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the risk of accidents for residents. Specific actions or inactions leading to this deficiency include the lack of appropriate hazard controls and insufficient monitoring or supervision in the affected area. No additional details about individual residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Update Care Plan After Resident Elopement
Penalty
Summary
The facility failed to update a resident's care plan with new interventions or monitoring following an incident of unauthorized elopement. The resident, who was admitted under guardianship with diagnoses including benign neoplasm of meninges and mild cognitive impairment, had a BIMS score of 7, indicating moderate cognitive impairment, and a documented history of wandering and attempted elopement. The resident's care plan allowed for leaving the premises to smoke, as permitted by the guardian, but did not include specific interventions to address the risk of elopement despite the resident's known behaviors and history. On a specific date, the resident independently arranged for transportation and left the facility without staff authorization to attend an appointment that had been cancelled by the guardian. The facility's Director of Nursing confirmed that, although the guardian refused the use of a wander guard and Adult Protective Services were notified, no new interventions or monitoring were added to the care plan to prevent recurrence of such incidents. This lack of updated care planning was not in accordance with facility policy, which requires defining how care provision will be changed or improved to protect residents after such events.
Some of the Latest Corrective Actions taken by Facilities in Wisconsin
- Updated the smoking policy to specify locked storage locations for all smoking materials to reduce unsafe smoking hazards (K - F0689 - WI)
- Educated staff on smoking policies/procedures, elopement protocols, monitoring for exit-seeking behavior, and verification of WanderGuard placement/function (K - F0689 - WI)
- Initiated routine audits to confirm smoking materials remain secured and WanderGuards are in place and functional (K - F0689 - WI)
- Revised the elopement policy to include guidance for situations when a resident removes a WanderGuard device (K - F0689 - WI)
- Educated facility and agency staff on abuse-prevention and restraint-use policies (J - F0604 - WI)
- Implemented mandatory elopement training during every staff member’s first shift to ensure competency from day one (J - F0689 - WI)
- Established a tiered auditing system for resident rounding and safety checks, with DON/ADON oversight and QAPI review of results (J - F0689 - WI)
Failure to Prevent Accident Hazards: Unsafe Smoking and Elopement
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards for two residents, resulting in deficiencies related to unsafe smoking practices and inadequate elopement prevention. One resident, who was cognitively intact and had a history of noncompliance with smoking policies, repeatedly smoked cigarettes in their room despite the facility's policy requiring smoking only in designated areas. The resident's care plan was not updated in response to multiple documented violations, and staff failed to revise the smoking assessment or implement additional safety interventions after incidents, including one where a hot cigarette butt singed trash in a shared bathroom. The resident's medical record also indicated a history of disruptive behavior and previous fire-related incidents in another facility, yet the facility did not adjust the care plan or restrict access to smoking materials accordingly. Another resident, with moderate cognitive impairment and a history of exit-seeking behavior, was not adequately supervised to prevent elopement. The resident's care plan required the use of a WanderGuard device and securing the window to prevent unsupervised exits. However, staff failed to ensure the WanderGuard was consistently in place and functioning, and the window in the resident's room was found to open fully, contrary to care plan instructions. The resident was observed without a WanderGuard on multiple occasions and was able to exit the building unsupervised through an emergency exit. Staff interviews revealed that the resident frequently removed the WanderGuard, and incidents of elopement were not documented or reported to administration as required. The facility's inaction in revising care plans, conducting new assessments, and ensuring the implementation of safety interventions for both residents led to a finding of immediate jeopardy. The lack of supervision and failure to enforce policies regarding smoking and elopement prevention created a situation where residents, including those with physical and cognitive limitations, were exposed to significant safety risks. Documentation and communication lapses further contributed to the ongoing deficiencies.
Removal Plan
- Remove smoking materials from R19's room and store them in a locked area.
- Reeducate R19 and have R19 sign the facility's smoking policy and behavior contract for smoking.
- Place R19 on checks to ensure smoking materials are not found in R19's room.
- Revise R19's care plan to reflect R19's current smoking plan.
- Update the facility's smoking policy to include information on where smoking materials will be kept to maintain safety and reduce the risk of unsafe smoking.
- Educate residents who smoke on the facility's smoking policy, review the designated smoking area, and collect all smoking materials for safe storage.
- Educate staff on the facility's smoking policy and procedure.
- Initiate audits to ensure all smoking materials remain locked and the smoking policy is being followed.
- Place a WanderGuard on R27 and review R27's order to ensure staff check placement, location, and function.
- Place R27 on checks to monitor R27's location and ensure safety.
- Secure the window in R27's room.
- Revise R27's care plan with updated interventions.
- Review residents at risk for elopement to ensure interventions are appropriate and in place.
- Educate staff on the facility's elopement policy and the importance of monitoring for exit seeking behavior.
- Educate staff on the importance of checking for WanderGuard placement and function.
- Review the facility's elopement policy to ensure information is included regarding what to do when a resident removes a WanderGuard.
- Initiate audits to ensure WanderGuards are in place and functioning properly.
Failure to Assess and Respond to Change in Condition Results in Resident Death
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident who experienced a significant change in condition. The resident, who had a history of type 2 diabetes mellitus, morbid obesity, polyneuropathy, hypotension, COPD, and sleep apnea, presented with symptoms including abdominal pain, nausea, distension, and changes in mental status. Despite these symptoms, staff did not document all of the resident's symptoms in the medical record, nor did they complete a thorough and ongoing RN assessment related to the change in condition. There were multiple instances where staff failed to perform a full set of vital signs, abdominal assessments, or pain assessments, even when the resident expressed severe discomfort and abnormal findings were present. The facility's own policy required prompt identification and effective action in response to changes in condition, including in-depth RN assessments and immediate notification of the attending practitioner. However, documentation shows that these steps were not consistently followed. For example, when the resident reported severe abdominal pain and other symptoms, staff administered medications but did not perform or document comprehensive assessments or notify the physician in a timely manner. Critical lab results indicating hyperkalemia and abnormal kidney function were not acted upon with the urgency required, and vital signs that warranted immediate physician notification were not communicated as per standard protocols. Additionally, there was a lack of ongoing monitoring and documentation of the resident's deteriorating condition. Interviews with facility leadership and staff confirmed that expected assessments and documentation were not completed, and that the medical record did not accurately reflect the resident's symptoms or the care provided. The failure to document and respond appropriately to the resident's change in condition, including not notifying the physician of critical changes and not providing continued monitoring, contributed to the resident's continued decline. The resident was eventually transferred to the hospital, where he was found to be pulseless and nonbreathing and subsequently expired due to a critical potassium level.
Removal Plan
- LPN R's employment was terminated.
- Vitals were taken on all residents to ensure no change in condition or need for additional assessment.
- Educational in-services on change in condition were provided for all clinical staff.
- Interviewed all residents and [NAME] of Attorney regarding comfort with cares and facility responsiveness to clinical needs to ensure the facility continues to meet the resident needs to their satisfaction.
- DON B performed chart review for all residents to ensure all changes in condition noted were accompanied by follow-up assessments and proper notification.
- DON B organized a skills fair for nursing to ensure competence in assessments, evaluations, nursing skills, and clinical judgement.
- Management team revamped morning meeting process with additional audits and accountability on 24 hour board.
- Continue audits and education on Stop and Watch program for entire staff. DON B will continue to provide scenarios.
Resident Physically Restrained by CNA Using Nightgown and Blanket
Penalty
Summary
A resident with Alzheimer's disease, hemiplegia, hemiparesis, major depressive disorder, and aphasia, who required total assistance for lower torso care and had a history of tearing apart incontinence briefs, was physically restrained by a Certified Nursing Assistant (CNA) during a PM shift. The CNA tied the sleeves of the resident's nightgown closed with the resident's arms inside and tucked a blanket across the resident's lap and under both sides of the mattress. This action was taken after the resident repeatedly attempted to remove their brief. As a result, the resident was unable to access their hands, move freely in bed, or reach the call light. The restraint was discovered by a Licensed Practical Nurse (LPN) during a routine check on the next shift, approximately two and a half hours later. The LPN found the resident with their arms inside the nightgown and a blanket tucked under the mattress, immediately untied the sleeves, and provided care. The resident was assessed for physical and psychological harm, with no new injuries noted, although bruising was observed on the tops of the resident's hands, which was determined not to be new. The resident, when interviewed, was only able to provide limited responses but indicated feeling fine and not having been hurt. Staff interviews and record reviews confirmed that the CNA had restrained the resident to prevent them from tearing at their brief and throwing items. The facility's policy prohibits the use of physical restraints for discipline or convenience and defines a physical restraint as any method that restricts freedom of movement or normal access to one's body. The CNA acknowledged in a statement that tying the sleeves was a poor decision, and the facility determined that the resident had been restrained during the last rounds of the PM shift.
Removal Plan
- Initiated physical and psychosocial monitoring for R1.
- Completed skin assessment for other cognitively impaired residents.
- Notified CNA-C's staffing agency and did not allow CNA-C to return to the facility.
- Educated facility and agency staff on the facility's abuse and restraint policies.
Failure to Ensure Residents Are Free from Significant Medication Errors
Penalty
Summary
Three residents receiving intravenous (IV) antibiotics experienced significant medication errors due to failures in medication order clarification, unauthorized changes to physician orders, and missed doses. One resident was admitted with a complex medical history including osteomyelitis, bacteremia, and acute kidney injury, and had a hospital discharge order for IV cefepime. Staff did not recognize a dosing error in the discharge order and entered it incorrectly into the facility's system. Subsequently, a registered nurse changed the order without consulting a physician, resulting in discrepancies between the hospital discharge order, the facility physician's order, and the nurse's revised order. The resident missed three doses of IV antibiotics over four days, and there was no documentation that the physician was notified of these missed doses. Another resident with multiple chronic conditions, including pneumonia, MRSA infection, and diabetic foot ulcer, had a physician order for IV vancomycin. The medication administration record (MAR) showed that a scheduled dose was not administered, and there was no documentation that the physician was notified of the missed dose. Additionally, a change in the administration time was communicated to the infectious disease office, but subsequent missed doses were not reported to the physician. A third resident with diagnoses including bacteremia, osteomyelitis, and diabetes was prescribed IV ceftriaxone via a PICC line. The MAR indicated that a scheduled dose was not administered because the resident was away from the facility for a physician appointment. There was no documentation that the physician was notified of the missed dose, and the facility physician confirmed that they were not made aware of the missed administration. In all cases, the facility failed to ensure that IV antibiotics were administered as ordered and that physicians were notified when doses were missed.
Removal Plan
- Review R203's medication orders for accuracy and availability and notify Infectious Disease (ID) of missed doses.
- Audit all residents on antibiotics and verify their medications are available and being administered.
- Educate nursing staff on the facility's policy for administering medication per physician orders and what to do when medications are unavailable.
- Educate nursing staff on confirming pharmacy orders with the physician and that nurses may not change medication orders without physician approval.
- Initiate audits to ensure admission orders are transcribed correctly and have been received from the pharmacy.
Failure to Prevent Elopement and Inadequate Supervision Resulting in Resident Harm
Penalty
Summary
The facility failed to ensure adequate supervision and accident hazard prevention for two residents, resulting in actual harm. One resident, with a history of elopement, dementia, mood disturbance, and protective placement by court order, repeatedly expressed a desire to leave the facility and had previously left medical appointments early or eloped. Despite these documented behaviors and a prior incident where the resident eloped from a hospital appointment, the facility did not implement a proactive elopement care plan or provide supervision during off-site appointments. The resident was again sent to a hospital appointment unaccompanied, where he eloped and was found at a hotel several hours later. Staff interviews revealed a lack of awareness of the resident's prior elopement history and no clear rationale for allowing the resident to attend appointments alone, despite known risks. Another resident, with diagnoses including repeated falls, cognitive impairment, and dependence on staff for mobility and self-care, was found outside the facility unattended for over an hour on a hot day. The resident was discovered by staff arriving for their shift, exhibiting signs of dehydration, heat exposure, and renal insufficiency, and required hospitalization. Prior to this incident, there was no protocol in place to monitor unsupervised residents who exited the building to go outdoors. Staff interviews indicated that residents considered independent were not routinely checked on when outside, and there was no clear system to track how long a resident had been outside or to ensure their safety while off the unit or building grounds. The facility's lack of proactive assessment, individualized care planning, and supervision for residents at risk for elopement or harm resulted in both residents experiencing actual harm. The absence of effective monitoring protocols and staff awareness contributed to the failure to prevent these incidents, as evidenced by the residents' ability to leave unsupervised and suffer adverse outcomes.
Removal Plan
- Affected resident continues to have periodic onsite checks in alignment with resident rounding policy.
- All Staff will be educated regarding elopement on their very first shift in their work unit.
- R2's care plan has been updated to require attendant at each external appointment/outing.
- Facility has made contact with the Guardian who is agreeable to a care plan meeting to discuss possible placement in the community, as this is what the member expressed a desire to do.
- Facility has reviewed court determined member rights restrictions and has updated R2's care plan to reflect any/all court order rights and/or removals.
- Member's care plan has been updated to include checks whether member is in the building or anywhere on the premises.
- Facility reviewed Member rounds policy and member elopement policy. The policies remain appropriate.
- DON, ADONs and or designated licensed staff will audit member rounding and safety checks on all residents. If no concerns noted, will perform audit every two weeks. If no concerns, will perform audits monthly. If no concerns, random audits will be done.
- All Audits will be reviewed during the facility's QAPI meetings.
- Facility will ensure attendant goes to every off-site appointment the member has, attendant will be identified in the appointment note in the EHR (Electronic Health Record).
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