West Melbourne Health & Rehabilitation Center has been cited for failing “to provide a secure
environment and adequate supervision” for a resident. “These failures contributed to the elopement of [the resident] and placed him at risk for serious injury/impairment/death. While [the resident] was out of the facility unsupervised, there was high likelihood he could have been hit by a car, fallen or become lost,” according to the citation.
Just before 2:00 pm, a staff member unlocked a door near the nursing home facility’s therapy gym. The resident mentioned in the citation left the facility unsupervised, which means that the resident did not have a nursing home staff member or a family member to help him avoid any dangerous scenarios while outside of the nursing home. This resident “had short-term and long-term memory problems, impaired vision, was only sometimes understood, and his ability was limited with making concrete requests,” all of which put him at serious risk for injury, impairment, or death, as the citation mentioned. The resident walked along a heavily-trafficked six-lane highway until a stranger, known as a Good Samaritan in the citation, drove the resident to his family’s home. The resident’s daughter came back to the facility with the Good Samaritan and the resident approximately 90 minutes after the resident eloped. The facility did not know where the resident was during this 90 minutes.
This incident occurred on the resident’s second day in the facility. He had been admitted the previous day and assessed for elopement risk as a part of his admission to the nursing home. The citation goes into detail about the factors that put this resident at a high risk for elopement, or leaving the facility unsupervised without the knowledge of nursing home staff.
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An Elopement Risk Review form completed on 11/01/19 at 3:50 PM, revealed the responses to risk factor screening questions were indicative of [the resident’s] high risk for elopement. The evaluation showed [the resident] had memory problems, psychiatric disorders, dementia, depression and was a new admission. Other risk factors identified during the admission evaluation noted [the resident] stated he wanted to go home, was confused, ambulated without assistance, paced without purpose and attempted to leave the facility. The document indicated [the resident] was observed wandering, intruded on the privacy of others and was at risk of getting to dangerous places. The Elopement Risk Review read, ‘Resident is at risk related to poor cognitive function, active exit seeking behaviors.’ A nurse’s progress note on 11/01/19 at 4:28 PM, read, ‘Resident exit seeking, (wander alert bracelet) placed on ankle for resident’s personal safety.’
The resident’s daughter spoke with the state investigators compiling this citation report. She explained that she and her family were no longer able to care for the resident because of his “worsening dementia.” The daughter had been with the resident the day before, when he was admitted to the facility. In the evening of the resident’s first day at the facility, the daughter received a phone call from the facility to notify her that nursing home staff had placed a wander bracelet on the resident after he attempted to leave the facility. The daughter said, “I broke down when I saw him. It was overwhelming and I started crying. My mom was very upset when she saw him at home. It added to her depression.”
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The daughter and the Good Samaritan drove the resident back to the nursing home facility. According to the daughter, the resident’s nurse had seen him earlier in the day with a suitcase, but no one at the facility knew that the resident was missing. The Good Samaritan stated he was “driving along the busy 6-lane highway and observed an older gentleman, [the resident], standing at the corner of a major intersection…. He was talking to himself and pointing in different directions.” The Good Samaritan explained [the resident’s] behavior was so unusual that he continued to observe him and was alarmed when he stepped off the curb and crossed the intersection through the flow of on-coming traffic. He said that “[the resident] waved his hat at the cars to stop them as he crossed the 6-lane road.”
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The Good Samaritan drove past the resident and pulled into the driveway of a business as the resident continued to walk along the sidewalk with his suitcase. He got out of his car, approached the resident, and asked if he was alright. The resident informed him that he was just released from the hospital and did not have a ride home. The resident did not have any identification with him but was able to provide his home address. The Good Samaritan drove the older man to his daughter’s home approximately 20 minutes away and told her he found her father wandering across a busy intersection. The resident did not want to return to the facility and resisted the daughter’s attempts to return him to the facility, so the Good Samaritan offered to drive them both in his car.
The state investigator reviewed the security footage from the facility and found the resident leaving through the therapy gym door with a rolling suitcase at 1:53 pm. The footage also showed that two Certified Nursing Assistants (CNAs) were at the door at this time. One was coming inside, while the other CNA was carrying a large box outside. The CNA coming inside held the door open for the resident and the other CNA. The resident walked outside and out of camera view. In a later interview, the CNA who opened the door said that she “was not aware the man was a new resident in the facility,” and that “at the end of her shift she was not aware there was a missing resident.”
When the surveyor retraced the resident’s likely elopement route, they found a number of dangerous environments that the resident passed through before being found by the Good Samaritan.
Along the elopement route, [the resident] crossed 9 side streets and 17 driveways for businesses such as large retail stores, medical buildings and strip malls. The sidewalk had areas of uneven, cracked and broken pavement, and there were drainage ditches adjacent to the sidewalk…. Some intersections had raised and sloping sidewalks due to drainage structures underneath, creating a steep drop off to the adjacent highway. The heavily trafficked intersections and busy driveways were challenging to navigate as motor vehicles turned on red lights, and on 2 occasions [cars] did not stop before driving across the sidewalk and turned onto the main highway. During the 30-minute journey, the surveyors heard occasional horns and sirens of emergency vehicles in addition to the continuous noise of heavy traffic along the 1.2 mile elopement route.
The resident had been assessed as a elopement risk, so the facility created a care plan for elopement the afternoon the resident was admitted. The CNA who opened the door “did not follow the protocol” she should have, according to the facility’s Director of Nursing (DON). The DON clarified that new residents should be checked on every 30-45 minutes, rather than the planned every two hours, and that all staff should verify the identity of anyone who was leaving the facility. The DON and nursing home Administrator both said they “determined the root cause of [the resident’s] elopement was multiple employees made poor decisions.”
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