The Care Center at Pinellas Park has been cited after the elopement of a resident who had wandering behaviors, impaired short-term and long-term memory, impaired decision-making abilities, as well as a history of falls and impulsive behavior. The citation specifically mentions the facility’s failure to “prevent and report neglect through lack of supervision” for this resident.
The resident got out of bed, left his room on the second floor, took the key-pad secured elevator to the first floor of the facility, and walked outside without staff noticing. At this point, the resident had been placed on fifteen-minute checks as well as one-on-one supervision. One Certified Nursing Assistant (CNA) said in an interview with the state investigator compiling this citation that “corporate said no more one-on-ones,” leaving the resident with these frequent checks.
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In addition to allowing the resident to leave the nursing home unaccompanied, “the facility failed to accurately document [the resident’s] elopement by falsifying information.” The nursing home’s report stated that the resident was found on the first floor of the nursing home, but multiple nursing home staff “reported the resident was found outside, off the facility’s property, down the road, and across six lanes of traffic, by a traffic light at a busy four-way intersection.”
Further review of the resident’s file shows that he was clearly at risk of elopement, or leaving the facility without supervision. The resident’s care plans showed that weeks before the incident, the resident had alteration or potential alteration in mood, acting more fidgety or restless at times. He was a fall risk as well, given his unsteady gait and impaired balance. The most recent fall was recorded a couple weeks before this incident, when he was found in another resident’s closet on the ground with his wheelchair outside the room. He was also evaluated as having impaired cognitive function and decision-making skills. His issues with short-term and long-term memories were attributed to his history of alcohol/drug abuse.
Just three days prior to the incident, the facility had created an elopement care plan. The facility planned to educate the resident or responsible party about the required sign-out procedure, perform frequent checks on the resident’s whereabouts, and provide redirection when the resident was going toward exit doors. The citation notes that “on the day the survey started [a staff member] revised the care plan to remove has a [history] of elopement.”
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Notes from the nursing staff provide a full picture of the resident’s disposition. About a month before the incident, a nurse noted that the resident had kept insisting he needed to go home. The nursing staff member explained that the resident was living in the facility for therapy, but had to continue to redirect the resident to avoid further confrontation. Other notes show that nursing staff “frequently redirected for safety.” The resident was noted as being alert but confused, trying to get in and out of his bed and chair without assistance despite his issues with balance and gait.
One CNA offered a clear explanation of the sequence of events on the evening of the resident’s elopement. They found the resident “walking up 49th Street,” at “about 8 o’clock at night.” The CNA’s full story regarding the resident’s elopement contradicts the facility’s report:
- I don’t remember him ever falling, but he would wander in and out of everyone’s rooms. It’s just the dementia. There is only so much we can do because of how many people we have to take care of. But anyways, his aide that night checked on [the resident] because he was on the 15-minute checks, then asked me to help him change another resident because that resident was being combative. When we were done [the other staff member] went and checked on [the resident]. Then, he came back to me and said, “Hey! can you help me find [this resident], he’s not in his room.”
- We couldn’t find him in any of the other rooms on the second floor. He wasn’t in the utility rooms; he was nowhere. So we checked on the third floor because he could’ve got on the elevator with someone…we have people coming on and off our unit all the time, but we couldn’t find him on the third floor either…. We told the staff up there and they said, “Let’s check the entire building.” We checked on the first floor; we checked outside and still couldn’t find him. So, then I said let me get in my truck and look for him. I found him as soon as I got onto 49th Street. I saw him walking by the stop light to the left when you are pulling out of the facility’s parking lot. He was by the intersection at the light.
- I asked “Where are you going?” and he said he was going home, he wanted to drink. I was able to get him in my truck and I brought him back. He wasn’t hurt or anything, so I brought him back up to his room on the second floor and his nurse, [a Registered Nurse (RN)], and I did an incident report…. [The resident] wasn’t gone long, maybe about 5 minutes because as soon as I got in my truck and got on the street I saw him.
The staff members involved acted quickly, trying to find the resident as soon as it became clear that he was not on his own floor. However, the CNA also mentions that they were overworked and had a lot of people to take care of: “There is only so much that we can do.” It is essential that nursing homes have adequate staff to care for each resident’s needs.
The Care Center at Pinellas Park put this resident in danger by allowing him to exit the facility without supervision or help, “putting [the resident] at risk of physical harm.” The resident crossed six lanes of traffic before a nursing staff member found him and was able to return him to the facility. The nursing home had an obligation to the resident as well as his family to provide a secure, reliable environment. Nursing homes are responsible for residents’ health and should put every measure in place to ensure the safety of residents.
If you suspect nursing home abuse, we will provide a free, confidential case evaluation with no obligation to hire us. We treat our clients with compassion and aggressively represent their rights, making nursing homes take responsibility for abuse. Distasio Law Firm has the expertise and ability to advocate for victims of nursing home abuse and neglect, even if a case goes to trial.