Resident Left Unsupervised in Facility Van During Transport
Penalty
Summary
A deficiency occurred when a resident with diagnoses including chronic obstructive pulmonary disease and depression was left unsupervised in the facility transportation van during a scheduled doctor's appointment. The staff member responsible for transportation admitted to leaving the resident alone in the vehicle with the window rolled down while he delivered lunch to his wife at a nearby hospital. The van's air conditioning was turned off, and the resident remained unattended for approximately 15 minutes. During this time, the resident exited the vehicle and entered the hospital to locate the driver, where a security guard provided assistance until the driver returned. The clinical record lacked documentation of the incident, and the event was not reported by the resident until over a week later. The facility's policy on transportation coordination and services required adherence to safety procedures, but these were not followed in this instance. The average high temperature during the week of the incident was 90 degrees, and the resident was not available for interview during the survey period. The deficiency was identified through interviews and record review, revealing a failure to provide adequate supervision and ensure the area was free from accident hazards during resident transport.