Hutsonwood At Brazil

During an interview on 8/14/25 at 1:18 p.m., Transporter 2 indicated on Friday afternoons, he reviewed the following weeks schedule and had noticed Resident B was in the hospital. He asked Unit Manager (UM) 4 and the DON if Resident B returned to the facility, would she be going to have the surgery on Monday morning, 8/11/25. He had been told by UM 4 that Resident B had already had her procedure when she was in the hospital.

The DON indicated she would confirm things and would contact him if the surgery was a go or no-go. He did not hear back from the DON or any staff at the facility. He arrived on Monday, 8/11/25, at his usual time, 8:00 a.m., and believed the surgery had already been completed while the resident was in the hospital.

The staff informed him that Resident B had missed her surgery.During an interview on 8/14/25 at 1:37 p.m., UM 4 indicated she had already gone home by the time Resident B returned from the hospital on Friday, 8/8/25.

Transporter 2 had come into the DON's office Friday afternoon, 8/8/25, and reviewed transports for Monday, 8/11/25.

The DON had told Transporter 2 they would not know for sure about Resident B's surgery until she returned with her discharge paperwork. UM 4 indicated the hospital had not contacted the facility for report prior to transfer back to the facility by the time she left the facility for the weekend.

During a telephone interview on 8/14/25 at 2:01 p.m., RN 3 indicated she looked where they kept the appointment paperwork for the day and saw Resident B was scheduled for surgery that morning.

The Surgery Center had called that morning, and she asked if she should hold her morning medications.

The Surgery Center staff indicated she could take her morning medications, but to hold her morning insulin injection. RN 3 got the resident ready and she was up in her wheelchair, and ready to go when Transporter 2 arrived approximately 7:45 a.m.

She noticed at 7:55 a.m., he had not left the facility for transport yet.

Transporter 2 indicated he had spoken to the DON and the surgery for that morning had been cancelled. RN 3 returned the resident to her bed and administered her insulin dose.

The resident's spouse arrived a little bit later and asked why she had not arrived for her surgery. He was very upset because the procedure was not cancelled.

She interrupted the staff's morning meeting to let the Administrator and DON know the resident's husband was there to talk with them regarding his wife being a no-show for her surgery.

She felt when Transporter 2 had told her the surgery was cancelled, she should have called the DON at that time to confirm.

She felt bad about not confirming, but he had seemed so sure of the cancellation.

She had not had access to the discharge paperwork from the resident's hospital stay, as they had been given to the DON or UM 4 to be reviewed and entered into the electronic health record after the weekend.

She had explained to Transporter 2 that she had been contacted by the Surgery Center and the surgery was confirmed. A current facility policy, dated 1/1/25, titled, Transporting a Resident (Facility Van), provided by the DON on 8/14/25 at 3:33 p.m., included the following: Policy: It is the policy of this facility to provide residents safe, non-emergency transportation to doctor's appointments, activity outings, and any other trips the facility deems necessary.A current facility policy, dated 1/1/25, titled, Consulting Physician/Practitioner Orders, provided by the DON on 8/14/25 at 3:33 p.m., included the following: Policy Explanation and Compliance Guidelines: .2 For consulting physician/practitioner orders received in writing or via fax, the nurse in a timely manner will: .b.

Document the verification order by entering the order into the EMRThis citation relates to Intake 2586289.3.1-37(b)

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