Livia Health: Resident Left in Van 5 Hours - NJ

The resident had been picked up from dialysis at 4:30 p.m. on February 10. The van driver parked at Livia Health and Senior Living at 5:00 p.m., then walked away without checking that his passenger had gotten out. Nobody realized the resident was missing until nearly 10 p.m.

Security footage captured the van arriving in the parking lot at 4:59 p.m. At 5:02 p.m., the driver exited and walked toward the back of the building. He waved at someone in another van, then disappeared from view.

The resident remained trapped inside for the next five hours and 25 minutes.

At 9:48 p.m., the assigned nurse reached out to the nursing supervisor to ask about the resident's return. The supervisor called the dialysis center three times but got no answer. She initiated a building search and checked the transfer log.

At 10:02 p.m., she called the resident's family member. The search continued.

At 10:04 p.m., she called the van driver to confirm the resident had returned to the facility. The driver said yes, he had brought the resident to their room. The search continued anyway.

At 10:21 p.m., the nursing supervisor walked outside to check the van. She walked around it with her cell phone light, checking both sides, then returned to the building while talking on her phone.

At 10:26 p.m., she walked back to the van.

At 10:27 p.m., she opened the van and found the resident lying on the floor with a wheelchair positioned behind them.

The supervisor ran back to the building to request help. She started the van to warm it, then additional staff arrived with blankets. They transferred the resident to a wheelchair and brought them inside.

The resident's initial temperature was 92 degrees. They told staff, "I am cold."

An ambulance was called at 10:43 p.m. The resident was transferred to the hospital for hypothermia treatment after being exposed to cold for five hours.

The van driver told inspectors he had driven the resident "on several occasions" and was "not focused at that time." He said the resident "was in her wheelchair, put her in the vestibule, put on her seatbelt, and she was fine and did not complain of any pain or discomfort."

When asked why he left without ensuring the resident got out, he said: "In my mind, I wanted to go back to the building to finish some work. When the Supervisor called me that night, it was shocking to me. I was emotional."

The receptionist's statement revealed gaps in the facility's tracking system. She wrote that around 10 p.m., the nursing supervisor asked if she had seen the resident return from dialysis. The receptionist checked her log and found the return time was blank.

"Sometimes, I have to step away from the desk to either use the bathroom, let someone from Memory Care, or find a nurse," the receptionist wrote. "So I thought [the driver] came and brought her to the room. I didn't see so I called him to confirm around 10:08 pm, and he said yes, he had brought her to her room."

The resident suffered from end-stage renal disease, heart problems, muscle weakness, and moderately impaired cognition. Their care plan noted they needed hemodialysis three times per week with pickup at 10:30 a.m. and treatment starting at 11:15 a.m.

Federal inspectors classified the incident as immediate jeopardy, the most serious level of violation. Both the van driver and the assigned nurse were suspended and subsequently terminated.

The facility implemented what it called a "child check-mate system" after the incident — an alarm that reminds drivers to check for passengers after each route. They also created a resident transport safety checklist requiring two staff signatures to confirm all transported residents have returned safely.

But the policies in place before the incident were already detailed. The facility's tracker policy, revised after the incident, required the receptionist to record when residents left and returned, send emails to staff about departures and returns, and alert the nursing supervisor if residents didn't return within expected timeframes.

The transportation policy required drivers to sign the tracking log upon returning residents to the facility.

None of these safeguards worked on February 10.

The receptionist stepped away from her desk and didn't see the resident return. The driver lied when asked directly if he had brought the resident inside. The tracking log showed a blank return time, but nobody investigated until nearly five hours later.

A separate violation found that staff routinely failed to document basic care for residents with severe dementia and mobility problems. For one resident at risk of malnutrition and skin breakdown, nursing assistants left blank spaces in care records on dozens of dates in October and November 2024.

The gaps covered bed mobility assistance, eating help, and nutrition tracking across all three shifts. On some days, no care was documented for breakfast, lunch, or dinner.

"If the DSR contained blank spaces, we don't know what care was given," the Assistant Director of Nursing told inspectors.

The Director of Nursing confirmed the same problem: "If the DSR contained blank spaces, there was no way to know if the care was provided or not."

The resident forgotten in the van spent the night in the hospital being treated for hypothermia. Their niece was notified at 11:31 p.m., more than six hours after the van had returned to the facility parking lot.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Livia Health and Senior Living from 2025-02-26 including all violations, facility responses, and corrective action plans.

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