CHARLOTTE, NC. Resident #97 never made it to her gastroenterologist appointment on January 15, and eight months later, nobody at Pelican Health Randolph LLC could explain why.
The appointment scheduler at the gastroenterologist's office confirmed during a phone interview that the resident had an 11:00 AM appointment that day. No one showed up. No one called to cancel.
The resident never got another appointment scheduled.
When state inspectors interviewed the facility's transportation scheduler in September, he said he didn't remember Resident #97 at all. He couldn't recall making transportation arrangements for her January appointment and didn't know why she wasn't scheduled for transportation.
The transportation scheduler explained his process: he looked through the facility appointment book daily and arranged transportation for residents who had appointments scheduled. If he saw "EMS" written beside an appointment, he did nothing because he didn't schedule EMS transportation and didn't know who was supposed to handle that.
He used the facility van for dialysis appointments and contracted transportation services for everything else.
Nobody seemed to know whose job it was.
The former assistant director of nursing, who held that position when the appointment was missed, remembered Resident #97 but couldn't recall any issues with her feeding tube. She didn't know why transportation wasn't scheduled for the appointment.
She said the social worker would make appointments for residents and write them in the appointment book, then the transportation scheduler would make the necessary arrangements.
But the former social worker who was employed when the appointment was missed couldn't be reached for comment despite multiple attempts.
The current administrator wasn't working at the facility in January when the appointment was missed. During her phone interview, she said her expectation was that residents would have transportation scheduled to avoid missing appointments. She confirmed it would have been the social worker at the time who scheduled appointments and wrote them in the appointment book.
The former medical director also couldn't be reached despite attempts on two separate days.
The inspection revealed a system where multiple staff members had pieces of responsibility for getting residents to medical appointments, but no single person was accountable when the system failed.
The transportation scheduler handled the logistics but relied on others to tell him about appointments. The social worker scheduled appointments and recorded them but depended on the transportation scheduler to arrange rides. The assistant director of nursing oversaw the process but didn't track whether residents actually made it to their appointments.
When Resident #97's appointment fell through the cracks, the breakdown went unnoticed for months. The gastroenterologist's office had no further appointments scheduled for her, suggesting no one from the facility ever called to reschedule.
The missed appointment represents more than an administrative error. Gastroenterology appointments often address serious digestive issues, particularly concerning for nursing home residents who may have feeding tubes or other complex medical needs. The inspection noted Resident #97 had feeding tube issues, though the former assistant director of nursing claimed not to recall them.
Federal regulations require nursing homes to ensure residents receive necessary medical care and services. This includes arranging transportation to medical appointments and maintaining systems to track whether residents actually receive the care that's been scheduled.
The inspection found the facility failed to maintain adequate systems to ensure Resident #97 received her scheduled medical care. The violation was classified as minimal harm with few residents affected, but it exposed systemic problems in how the facility coordinated medical care for its residents.
Eight months after the missed appointment, the facility's staff turnover had eliminated most of the institutional memory about what went wrong. The social worker who scheduled the appointment was gone. The medical director was gone. The administrator was gone.
Only the transportation scheduler remained, and he couldn't remember Resident #97 at all.
The gastroenterologist's office confirmed she never rescheduled.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pelican Health Randolph LLC from 2025-09-17 including all violations, facility responses, and corrective action plans.