F0689

J

Resident with Dementia Left Unattended in Transport Van for Several Hours in Cold Weather

Desoto, Texas Survey Completed on 03-03-2026

Penalty

Fine: $15,940

Summary

The deficiency involves the facility’s failure to ensure a resident remained free from accident hazards and received adequate supervision, resulting in the resident being left unattended in the facility’s transport van for several hours in cold weather. The resident was an older 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 need for dialysis three times a week.

On the day of the incident, the resident returned from dialysis in the late afternoon, typically between 4:30 PM and 5:00 PM, according to staff and family interviews. The facility’s driver stated he brought the resident back to the unit around that time and informed staff that the resident had returned. However, later that evening, a CNA noted that the resident was not in the common area or in his room when she checked around 8:00–8:30 PM and notified the nurse that she could not locate him. Staff then began searching the unit and other units in the facility.

During the search, the CNA went out to her car and noticed movement inside the facility’s transport van parked under the portico. She found the driver’s side door locked, returned to get the nurse, and staff were able to open the passenger side doors. They found the resident seated in the van, buckled into a seat with his seat belt on, wearing a coat and sweater, and his wheelchair stored in the back of the van. Nursing staff present at the scene stated they did not believe the resident, given his dementia and physical condition, was capable of independently exiting the locked unit, wheeling himself outside, folding and loading his wheelchair into the van, and then buckling himself into a seat. The resident told staff that the driver had left him in the van and that he thought the driver was going to come back. Weather records showed outdoor temperatures in the mid-30s Fahrenheit during the time the resident was in the van. The resident’s electronic health record contained no progress notes documenting the incident, the interventions performed, or who was notified.

The facility’s policy titled "Safety System for Residents" addressed general resident safety but did not address leaving residents outside. Interviews with the DON and Administrator reflected differing views on how the resident came to be left in the van, with the driver and Administrator asserting the resident had been returned to the unit and somehow made his way back to the van, while nursing staff expressed doubt that the resident could have done so independently. The incident was determined to constitute non-compliance that rose to the level of Immediate Jeopardy for a period of several days, during which the resident remained at risk of harm related to exposure to cold temperatures, discomfort, pain, and anxiety.