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F0689
D

Resident Placed at Risk During Transport by Impaired Van Driver

Ebensburg, Pennsylvania Survey Completed on 04-08-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident, who was cognitively impaired and had communication limitations, was being transported to an orthopedic appointment. The nurse aide escorting the resident reported that the van driver arrived late, appeared drowsy, and drove the van at an unusually slow speed. During the trip, the driver began to fall asleep and swerved off the road, prompting the nurse aide to fabricate a story about the appointment being canceled in order to return safely to the facility. Upon return, the nurse aide immediately reported the incident to supervisory staff. A reasonable suspicion report documented that the van driver exhibited signs of intoxication, including sleepiness, bloodshot and droopy eyes, slurred speech, and difficulty standing. A subsequent blood alcohol test confirmed the driver had a blood alcohol level of 0.122 percent while responsible for transporting the resident. This incident demonstrated a failure to maintain an environment free of accident hazards and to provide adequate supervision to prevent accidents during resident transportation.

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