Resident Misses Appointment Due to Lack of Assistance
Summary
The facility failed to provide necessary assistance with grooming and dressing for a resident who had a scheduled physician's appointment, resulting in the resident missing the appointment. The facility's policy on resident rights emphasizes the importance of assisting residents in maintaining their self-esteem and ensuring reasonable accommodation of their needs. However, the resident, who was dependent on staff for dressing and bathing due to conditions such as osteomyelitis, peripheral vascular disease, and diabetes, did not receive the required assistance in a timely manner. This lack of assistance led to the resident being unprepared when transportation services arrived, causing her to miss her medical appointment. The resident, who had intact cognition as indicated by a BIMS score of 15, expressed that she missed her appointment because she was not helped in time to get ready and reach the transportation service. Interviews with the resident and staff, including the Director of Nursing and a Certified Nurse Assistant, confirmed that the resident required substantial assistance for dressing and that staff should have provided timely help. The Director of Nursing acknowledged that the resident does not move quickly and should have been assisted to ensure she was ready for her 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 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 did not receive assistance from the facility in arranging transportation to and from radiology services, leading to missed or uncoordinated appointments.
Two residents with significant mobility impairments missed or were late to scheduled medical appointments due to the facility's failure to arrange timely transportation and communicate appointment schedules among staff. Miscommunication and lack of awareness among nursing staff contributed to these deficiencies.
A resident missed a scheduled knee x-ray and physician visit because staff failed to arrange necessary transportation, despite appointment paperwork being present at the nurses station and communication between staff about the appointment. The resident was not provided the required assistance, resulting in the missed medical appointment.
A resident missed several radiology appointments due to the facility's failure to secure transportation, as they did not have access to a bariatric stretcher and had not paid the transportation company. The resident, with conditions including dementia and high blood pressure, was unable to attend necessary CT scans and a biopsy, which were crucial for determining a potential cancer diagnosis.
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).
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.
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.
Failure to Arrange Timely Transportation for Medical Appointments
Penalty
Summary
The facility failed to ensure transportation was properly arranged for two residents, resulting in missed or delayed medical appointments. One resident, with a history of hemiplegia and generalized muscle weakness, missed a scheduled primary care appointment because transportation was not arranged in a timely manner. The receptionist was only notified of the appointment on the day it was scheduled, and when transportation arrived, the resident was not ready. The charge nurse assigned to the resident was unaware of the appointment, and the facility's progress notes indicated that transportation was servicing another resident at the time, necessitating a reschedule. Another resident, diagnosed with a left tibia fracture, foot sprain, and generalized muscle weakness, arrived late to an orthopedic appointment due to delayed facility-owned transportation and was unable to be seen by the physician. The resident reported feeling unimportant due to the lack of prioritization for her scheduled pick-up. Staff interviews revealed miscommunication and lack of awareness among nurses and CNAs regarding residents' appointments, contributing to the missed and delayed appointments.
Failure to Arrange Transportation for Scheduled X-ray Appointment
Penalty
Summary
A deficiency occurred when the facility failed to assist a resident in arranging transportation for a scheduled x-ray appointment. The resident, who had been admitted in December 2024, was supposed to have a knee x-ray at an orthopaedic clinic. The resident reported being upset after being informed by the staff member responsible for transportation arrangements that they were unaware of the appointment and had not set up transportation. Another staff member confirmed seeing paperwork regarding the appointment at the nurses station and communicated this to the transportation coordinator. Further interviews confirmed that the resident had been given paperwork with the appointment details during a previous clinic visit, but the necessary transportation was not arranged, resulting in the resident missing the scheduled x-ray and physician visit. The report is based on interviews with the resident and staff, as well as a review of the resident's medical record and communication with the orthopaedic clinic, all of which confirmed the missed appointment due to the lack of transportation arrangements.
Failure to Secure Transportation for Radiology Appointments
Penalty
Summary
The facility failed to assist Resident R1 in securing transportation to a radiology appointment, as required by their policies. Resident R1, who was admitted to the facility with diagnoses including high blood pressure, dementia, and age-related physical debility, missed several scheduled CT scans and a biopsy due to the facility's inability to provide necessary transportation. The facility's policy mandates assistance in arranging transportation for services not covered, but Resident R1's appointments were missed because the facility did not have access to a bariatric stretcher and had not paid the transportation company. Interviews with staff revealed that the facility was unable to secure transportation from early February to late March due to nonpayment to the transportation company. The Director of Transportation and the Transportation Scheduler confirmed that Resident R1 missed appointments because the facility could not pay for the transport service that provided a bariatric stretcher. The Director of Nursing also confirmed the facility's failure to obtain transportation for Resident R1's radiology appointments, which was necessary for determining a potential cancer diagnosis.
Plan Of Correction
1. The third-party transportation vendor was returned to service. Resident R1 attended their scheduled appointment with no negative effect to care identified. 2. An audit will be conducted to identify Residents who require appointments and to ensure, in the event the in-house fleet is unable to accommodate the trip, that the trip be made timely by a third-party transportation vendor. 3. The NHA will re-inservice the transportation director to ensure Residents who require appointments and to ensure, in the event the in-house fleet is unable to accommodate the trip, that the trip be made timely by a third-party transportation vendor. 4. Residents who require transportation to an appointment will be audited for two weeks by the transportation director. Audit findings will be shared with QAPI.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release August 26, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.