Resident Left Unsupervised in Transport Van After Dialysis
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple medical conditions, including dementia, hypertension, diabetes, and end stage renal disease, was left alone in the facility's transport van for an unknown period of time. The resident, who required extensive assistance for transfers and primarily used a wheelchair, was returning from an offsite dialysis appointment when the incident occurred. Upon arrival at the facility, the resident reported to staff that the van driver left her alone in the vehicle, and she did not know what to do. Documentation and interviews confirmed that the resident was left unsupervised in the van, with the exact duration remaining undetermined. The facility's records showed that, on the day of the incident, the post-dialysis vital signs were taken later than usual, suggesting a delay in the resident's return to her unit. Staff interviews indicated that, at times, only one staff member—the driver—was present on the van, as the transporter might stay with another resident at an appointment, leaving the driver alone to manage the return trip. On the day in question, the driver admitted to leaving the resident in the van while he attended to personal needs, only realizing afterward that the resident was still inside. The resident was found to be alert and verbal upon return to the unit, though she was described as flustered and emotional immediately after the event. Staff confirmed that her physical condition was stable, with no abnormal vital signs or signs of physical harm. The incident was reported through the facility's concern and comment process, and the resident's family was notified. The event highlighted a lapse in supervision and adherence to safe transport protocols, resulting in the resident being left in an unsafe environment.