F0609

D

Failure to Timely Report Alleged Neglect After Resident Left in Transport Van

Desoto, Texas Survey Completed on 03-03-2026

Penalty

Fine: $15,940

Summary

The deficiency involves the facility’s failure to immediately report an alleged incident of neglect involving a cognitively impaired resident who was left in a transport van for several hours in cold weather. The resident was an elderly male with kidney failure requiring dialysis, dementia, and paranoid schizophrenia, with a BIMS score of 6 indicating severe cognitive impairment. He used a wheelchair for mobility, required assistance with ADLs, and resided on a memory care unit. His care plan reflected delirium, impaired mobility, and a scheduled dialysis regimen three times a week. Despite this, the facility’s electronic health record contained no progress notes documenting the incident, the interventions taken, or who was notified.

On the day of the incident, the resident returned from dialysis in the late afternoon, typically between 4:30 and 5:00 PM. A family member reported being notified later that evening, around 8:30 PM, that the resident was not on the memory care unit, and then around 9:00 PM that he had been found in the transport van. A CNA working that evening stated she noticed the resident was not in the common area or his room around 8:00–8:30 PM and informed the nurse. Staff searched the unit and other units, and the CNA, upon going to her car, observed movement in the transport van. The van’s driver-side door was locked, but staff were able to open the passenger side and found the resident seated with his seat belt fastened; they used another wheelchair because they could not access his wheelchair in the van without the keys. The CNA reported the resident said that the driver had left him in the van and that he thought the driver would return.

Interviews with staff revealed conflicting views about how the resident came to be in the van. The driver stated he had returned the resident to the unit around 5:00 PM, informed staff of his return, and did not know how the resident got back to the van. The DON recalled being called at home that the resident could not be found, instructed staff to search the grounds, and was later informed the resident was found in the van; she believed the resident was capable of taking himself back to the van after following a visitor off the secured unit. An LVN, however, stated she did not believe the resident was capable of leaving the locked unit, wheeling himself out, folding and loading his wheelchair, and buckling himself into the van given his dementia and physical condition. The Administrator concluded from his investigation that the driver had returned the resident to the unit and that the resident managed to get back to the van, and he stated he did not report the incident to the state agency because there was no harm to the resident and the driver had brought him back to the unit. This decision was inconsistent with the facility’s written abuse, neglect, and exploitation policy, which required reportable allegations to be reported to the state regulatory agency and other authorities within specified timeframes.