Resident Left Unattended in Locked Facility Van After Medical Appointment
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple medical conditions, including dementia, was not returned to her room after being transported to a medical appointment. The Transportation Coordinator, responsible for safely transporting residents, returned to the facility with the resident but failed to unload her from the facility van. The resident, who was wheelchair-bound and dependent on staff for activities of daily living, remained locked inside the van for an estimated three to four hours during a period of severe weather, while the facility was under a code black for serious weather conditions. The Transportation Coordinator became distracted by multiple phone calls regarding other residents' appointments and impending poor weather, which led her to deviate from her usual routine. She parked the van in a different location than usual and went inside the facility to check the calendar, forgetting to unload the resident. There was no sign-out sheet or checklist in place at the time to ensure residents were accounted for after transport. The resident was discovered missing when an LPN became concerned about her whereabouts during shift change and initiated a search, eventually finding her in the locked van. Upon discovery, emergency services were called to gain access to the van. The resident was found alert, in her wheelchair, and assessed by medical staff, who determined she was at her baseline with no observed injuries or distress. The incident was reported to facility leadership, law enforcement, and other relevant agencies. The deficiency was cited under F 689 for failure to ensure the environment was free from accident hazards and to provide adequate supervision to prevent accidents.