Resident Left Unattended in Facility Transport Van
Penalty
Summary
A facility failed to ensure a resident's right to be free from neglect when a resident was left unattended and strapped in a facility transport van for approximately two hours after returning from a medical appointment. The Transportation Aide (TA) parked the van at the facility and went inside without removing the resident, who was unable to ambulate or call for help. The resident remained in the van, exposed to heat and without access to hydration, care, or supervision, until staff located her after her representative inquired about her whereabouts. The resident, who had diagnoses including Paroxysmal Atrial Fibrillation and Chronic Kidney Disease and a moderate cognitive impairment, was found to be hot, thirsty, weak, and emotionally distressed upon being discovered. She had urinated on herself, her face was puffy, her eyes were red, and her hands were swollen. The resident expressed fear and anxiety during the incident, stating she thought she might die and was afraid she would be left on the bus overnight. Staff interviews confirmed the resident's physical and emotional distress upon her return to her room. The TA admitted to being distracted by work-related concerns and failing to ensure the resident was safely returned to her room. The facility's policy required that residents be protected from neglect, and staff interviews, including those with the DON and Administrator, confirmed that the resident's care and safety needs were not met during the two-hour period she was left unattended in the van. The incident was determined to be Immediate Jeopardy and Substandard Quality of Care due to the facility's failure to provide necessary care and supervision.
Removal Plan
- Hold a Quality Assurance (QA) meeting.
- Provide in-services with all staff.
- Complete a health assessment and monitoring for Resident #1.
- Notify reporting officials of the incident.
- Monitor through the QA program.
- Director of Nursing and Assistant Director of Nursing utilize End-of-Route Witness Audit Form to monitor both the vehicle walk-throughs and the completion of the End-of-Route Two-Person Checklist.
- Conduct monitoring.