Peninsula Care and Rehabilitation Center has been cited after a resident eloped from the facility and fell on their face, hands, and knees more than five miles from the facility. The Florida Agency for Healthcare Administration has cited this nursing home for failing “to revise the care plan to incorporate the identified problem area of elopement risk and implement care plan interventions to keep the resident safe.”
This resident was not evaluated as an elopement risk when she was admitted to the nursing home. Elopement is a term used for nursing home residents who wander or leave a facility without notice. Many facilities have sign-out procedures when a resident who may have issues with memory, mobility, or cognition leaves with a family member for a short amount of time. Nursing homes are responsible for keeping all residents safe and healthy, and following these procedures is meant to ensure that residents who would not be safe on their own have support when they leave the facility.
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In this case, the nursing home had documented the resident’s wandering, packing of clothes, and asking to leave. The resident’s picture was posted at the employee time clock, nursing station, and front desk area “with the words ‘Elopement Risk’ on it.” The nursing home had clearly identified the signs that this resident was at risk of trying to leave the facility and put herself in a dangerous situation. Two weeks prior to the resident eloping from the nursing home, Peninsula Care and Rehabilitation Center’s Speech Therapy started helping the resident with reorientation to the facility, cognitive impairment, and reducing “exit seeking,” a term for a resident who has shown an inclination to leave a nursing home unsafely.
The resident left the facility without a nursing staff member noticing; the facility was not even sure which door the resident took to leave the building. One staff member reported that the resident was missing at 8:10 am. The Director of Nursing called the police at 9:12 am, and police came to the facility at 9:20 am. She walked 5.3 miles “along heavily traveled roads, crossed the highway to a parking lot where she fell on her face, hands and knees.” A stranger saw the resident fall and reported the situation to emergency services. Bystanders who witnessed the fall said that she got up quickly after the fall. The Nursing Home Administrator found out that the resident was found at 9:39 am. The resident was taken immediately in an ambulance from the parking lot where she fell to a local emergency room.
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Notes from the emergency room record showed that the resident had “multiple facial contusions, and extremity injuries, but [appeared] to be [walking].” The resident was nervous and anxious in the hospital, unsure of where she was. A family member was with her and said “this [was] much worse than her normal mentation,” or mental activity. The emergency room staff noted that the resident appeared to be on blood thinners, which can cause side effects of dizziness or weakness. A nursing home resident on blood thinners could be more likely to fall if they are experiencing dizziness and are more likely to experience more serious injuries like a blood clot after a fall.
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Even though the facility had noted the resident’s behavior and risk of elopement, there were no updates to the resident’s care plan “to reduce the risk of exit seeking behavior.” The facility, according to the citation, should have created “interventions to reduce unsafe wandering.” Once the resident was reported missing, the facility “checked all the doors for functionality,” checked likely locations where the resident could be, interviewed staff, and notified the State, as is required in such a situation. They also checked on all other residents in the facility, making sure that there were no changes that nursing staff had missed. The Nursing Home Administrator said she did not call the police, but confirmed that they updated the resident’s care plan to address elopement.
The nursing home also had their door company come and make sure the doors were working properly, posting nursing staff members at the doors until the company arrived. The nursing home’s doors should not have been open for residents to leave at any point; a front door functions as the singular entrance and exit point for residents to minimize the danger a resident could encounter. This resident sustained a serious fall, which could have been addressed much faster if the resident were in the facility. A nursing home should keep loved ones safe, not put them more at risk.
The resident’s fall is important to note as well. Nursing home residents are often sensitive to falls due to medication or loss of balance, but are also more likely to have more serious consequences for falls. Damage to a resident’s mobility or cognition can have effects on the rest of their lives, perhaps even reducing a resident’s quality of life. State nursing home regulations place a high value on the health and safety of residents, leading to clear requirements for nursing homes to follow. In this case, the state investigators found that the nursing home did not protect the resident as it should have.
The citation regarding this incident clearly states what the nursing home failed to do to protect this resident: “The facility failed to implement [its own] Elopement / Wandering policy and procedure by not…reassessing [the resident], who was identified as a elopement risk; not care
planning for the identified elopement risk problem; and not providing interventions to
reduce or prevent elopement risk.” A resident’s care plan needs to have up-to-date, relevant information about a resident’s health and behavior, in addition to a clear and helpful plan of action for preventing harm and promoting the resident’s well being.
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