Resident Wanders from Nursing Home to Busy Street
Bay Pointe Nursing Pavilion has been cited after a resident who had been deemed unable to make her own health decisions left the facility. The resident eloped from the nursing home without being noticed by nursing staff, walked on a public sidewalk in the direction of her daughter’s house, passed a wooden lot, and was out of view of the facility.
A nursing home staff member saw the resident standing in a patch of grass between the sidewalk and a busy street as they were driving back to the facility from lunch. The staff member brought the resident back to the nursing home and reported the incident to the Nursing Home Administrator and the Director of Nurses. These two administrators of the facility, however, did not come to the facility to investigate until the next day. This means that the nursing home waited a full day to start an investigation and to ensure all residents in the facility were safe. Nursing homes should check on all residents in the facility in such a situation and begin an investigation right away.
The resident had multiple medical concerns. She was on medication for depression and an anticoagulant (blood thinner), among other medications, which she had refused to take. An anticoagulant is especially relevant in this case, as it could increase a resident’s risk of falling. Falls for nursing home residents can be especially damaging, resulting in injury and a decreased quality of life. It is unclear how recently the resident had refused her medication, however. The resident also had a recent syncopal episode (loss of consciousness), but would not go to the hospital. A year prior to the elopement described in this citation, the resident’s physician had determined that she was unable to make her own healthcare decisions. On this day, the National Weather Service “indicated extreme caution with the likelihood of heat disorders with prolonged exposure or strenuous activity.” The temperature high was 88 degrees Fahrenheit and temperature low was 79 degrees Fahrenheit. With an average relative humidity of 74%, the outside temperature would have felt like 100 degrees.
All of these factors signal that the resident was at a high risk of getting hurt during this elopement. The resident could have been injured while crossing a road, wandering into traffic, or gotten lost and unable to receive care outside the nursing facility. This was an unsafe situation not only for this resident, but for others as well. Neither the Nursing Home Administrator and the Director of Nurses initiated checks for other residents. Given that the nursing home staff did not notice this resident leave, other residents could have easily gotten hurt or wandered without the notice of staff.
Bay Pointe Nursing Pavilion staff disagreed with the state investigator’s assessment of the situation. The Director of Nurses said that this was not an elopement because the resident had left with her cell phone, intending to call her daughter because she was concerned that her daughter had not visited recently. The Risk Manager Specialist did not classify this incident as an elopement either, saying that the resident did not have a history of elopement, that she had a leave of absence order from the physician, and that the resident had not been hurt while walking down the sidewalk. The Risk Manager Specialist did agree that the resident had left the facility and was found down the street in front of an assisted living facility.
A leave of absence from a nursing home allows a nursing home resident to leave the facility for a day. This happens often for holidays, when a resident would stay with family for a gathering or to visit family. This does not mean, however, that a resident is able to leave at any time without a friend or family member to take care of them. This resident’s leave of absence order stated that the resident was able to leave the facility safely with an escort and her medication. The Nursing Home Administrator did not believe the resident had eloped “because the resident said she was safe, and she had her cell phone with her.” When the state investigator asked how the Nursing Home Administrator felt about the resident leaving without staff noticing, he said was only uncomfortable that she did not sign out when she left. The facility’s definition of elopement “occurs when a resident leaves the premises or a safe area without authorization.” This resident left without appropriate supervision, meeting the definition of elopement.
The resident was assessed for injury when she returned to the facility and did not appear to be injured. When the state investigator asked if this resident was a fall risk, the Director of Nurses initially said “no.” After being asked to show the resident’s care plan, however, the Director of Nurses stated that the resident’s medication classified her and all other residents taking this medication as a fall risk. The state investigator asked again if the resident was a fall risk, and the Director of Nurses said that all the residents’ care plans were not accurate and were in the process of being updated. This resident’s care plan stated that she was a fall risk because of gait or balance problems, psychoactive drug use, and required an assistive device or walker. The Director of Nurses immediately disagreed with this care plan, saying “she could outwalk me.”
The facility did not follow the correct procedure for evaluating this resident as a fall risk. After the incident, they also failed to follow the correct procedure for assessing the resident’s elopement risk. This incident did not result in injury to the resident, but the nursing home’s negligence put the resident at risk for serious harm. Multiple staff members confirmed the facts of the citation. The resident’s daughter was also interviewed for this citation, sharing that the resident had memory issues that made it unsafe for her to leave the facility alone. The resident also needs glasses to see, but does not always wear them. She said the resident is weak and may collapse if she walks too far. On a day that felt like 100 degrees, this resident was in immediate jeopardy when the facility failed to stop her from wandering outside alone.
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