MONTGOMERY, Ala. (WSFA) - The Alabama Department of Public Health has released its report on an investigation into a Montgomery assisted living facility after a woman was left inside a van for several hours in June.
The report from ADPH states that three employees at Elmcroft did not perform their duties on the day the woman was left inside the van. The investigation found that employees falsified documentation and stated they observed the woman at different times in the building while she was still in the van.
According to the report, the high temperature on June 19 was 88 degree.
The woman was taken to a hospital after she was found in the van. The report states the woman’s hospitalization was a “result of the facility’s failure to follow policies,” and the investigation found that a number of deficiencies at the facility resulted in an unsafe environment with significant harm to one resident and the potential for harm to all residents. To read the whole report, visit this link.
DETAILS FROM THE REPORT
The report states the woman was admitted to the facility on March 28. She had diagnoses of hypertension, psychosis, hypothyroidism, coronary artery disease, and neuropathy. She required assistance with bathing, dressing, and other activities. She could not walk and used a wheelchair or motorized scooter.
During the investigation, ADPH reviewed the facility’s policy for loading and unloading the community van. The policy states the driver should have a list of all residents on the van, and as each resident gets out of the van the driver or another staff member should mark off each resident to ensure they all safely exit. Once the van is presumed empty, the driver or other staff member should walk the length of the van, checking all seats, to verify all residents had disembarked.
On June 19, the report states the driver of the van returned the residents, five in total and one private duty sitter, to the facility at about noon after that day’s trip. She dropped off the residents at the front door before taking the van to its designated parking spot. The driver said she checked the rearview mirror but did not see anyone left in the van, so she disembarked and locked the door.
Before the trip the driver had loaded the woman onto the van using the wheelchair lift and helped her into a seat. The driver told ADPH she did not conduct a walk through of the van. She also did not complete a Vehicle Trip Log, which required documentation about the outing including time in and time out and the names of the residents on board, because no other employee had been completing it. The driver said she discarded a piece of paper containing the names of all the residents on the van when they returned to the facility. The private duty sitter said she saw the driver check off the names of the residents at a kiosk used to keep track of residents who participate in activities.
The report also states that an employee documented at 2:30 p.m. on June 19 that the woman attended lunch and did not require assistance, at which time the woman had been in the van for two and a half hours. The employee, who had been assigned to care for the woman, told ADPH she did not see the woman in the dining room for lunch so she put her food under a heat lamp. She left the dining room for a minute and when she returned the woman’s plate was gone. She assumed another staff member had taken the tray to the woman, and she did not seek out the woman to confirm.
On the afternoon of June 19, the report states the woman was supposed to have her blood pressure checked. At noon, an employee documented that she assessed the woman’s blood pressure and administered medication, and she documented the same thing at 2 p.m. She also claimed in a handwritten statement that she spoke with the woman several times before and around lunchtime and saw her with another resident at around 2 p.m. When she was relieved at the end of her shift by another nurse, the nurse pointed out there was a medicine cup still on the chart. The employee poured the medication into the sharps container, her usual practice for disposing of unused medications.
The medication was later carefully retrieved and matched back to the woman.
At 5 p.m., the relieving nurse began looking for the woman to give her her medicine. When she couldn’t find her, she notified other employees.
The employees searched the facility and called the woman’s family and 911 to report a missing person. They found the woman at 5:20 p.m. by looking through the windows of the van. She was lying on the floor, hot to the touch and shaking.
The woman was taken to a hospital. She suffered from acute heat stroke, acute kidney injury and acute respiratory failure. She spent 13 days in the hospital and was transferred to a rehabilitation facility before she died at home in July.