Resident #10, who has moderate cognitive impairment from a stroke and was scheduled for left eye cataract surgery, never made it to his appointment on September 17. Instead, the facility's driver transported an unidentified resident to the medical facility.
The mix-up occurred during the first appointment of the day. The driver, identified only as "DR" in inspection records, had been on the job for just a couple of weeks when he pointed at a resident and asked a nursing assistant on the floor if that was Resident #10.
"DR said he thought the CNA responded that was Resident #10, so DR said he then took that resident and not Resident #10 to the appointment," inspectors wrote.
The error went undetected until the Assistant Director of Nursing called the driver to inform him he had transported the wrong person. The driver then returned the incorrect resident to the facility.
When inspectors interviewed Resident #10 the morning after his missed appointment, he said he didn't know what had happened. A nursing assistant had told him the night before that his appointment was rescheduled.
"Resident #10 said that he had already had the surgery on his right eye," according to the inspection report. "Resident #10 said that things happen, and he will have it done when it is rescheduled."
The 78-year-old patient suffers from paralysis on his left side following a stroke, heart failure, and recurrent moderate depression. His cognitive assessment score of 10 indicates moderate impairment.
The driver acknowledged multiple protocol failures during his interview with inspectors. He admitted he was supposed to bring a face sheet with the resident's information to verify identity before transport, but didn't. He also failed to check the facility's computer system to confirm he had the correct patient.
"DR said it could negatively impact a resident by a resident having a procedure that should not have happened," the inspection found.
The Director of Nursing told inspectors the driver should have checked with a floor nurse rather than asking a nursing assistant in the hallway. She emphasized that drivers receive training on using the facility's computer system to verify resident identities.
"DON said that Resident #10 could have missed an important surgery," inspectors noted.
Multiple staff members confirmed the driver violated established procedures. The Administrator said staff are trained on the computer system and should know where to find resident face sheets for verification.
The facility's Assistant Director of Nursing discovered the error and made the call to retrieve the wrong resident. According to the Administrator, the driver has since been counseled and will now check with nurses in the hallway to verify resident identities.
The inspection revealed the facility lacked a written policy specifying what drivers should do to verify they have the correct resident when transporting patients to outside medical appointments.
The Director of Nursing said the driver was in-serviced on resident identification the same day the incident occurred. The facility rescheduled Resident #10's cataract surgery following the mix-up.
Federal inspectors classified the violation as having minimal harm or potential for actual harm, but noted it could place residents at risk for missing medical treatments. The finding represents a failure to provide appropriate treatment and care according to orders and resident preferences.
The driver's brief tenure at the facility and admission that he "thought" the nursing assistant confirmed the resident's identity highlight gaps in the facility's patient safety protocols. His acknowledgment that the wrong resident could have received an unnecessary medical procedure underscores the potential consequences of the identification failure.
Resident #10's calm acceptance of the missed appointment, telling inspectors that "things happen," reflects the vulnerability of cognitively impaired patients who depend entirely on staff to navigate their medical care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Legend Oaks Healthcare and Rehabilitation - North from 2025-09-17 including all violations, facility responses, and corrective action plans.
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