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“Resident #1 was found outside on the pavement face down with no pulse”

THE MEADOWS HEALTH AND REHABILITATION CENTER

LOCATED: 8383 MEADOW RD, DALLAS, TX 75231

THE MEADOWS HEALTH AND REHABILITATION CENTER was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies:

PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here.

FACILITY FAILED TO MAKE SURE THAT THE NURSING HOME AREA IS FREE FROM ACCIDENT HAZARDS AND RISKS AND PROVIDES SUPERVISION TO PREVENT AVOIDABLE ACCIDENTS

LEVEL OF HARM –IMMEDIATE JEOPARDY

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision to prevent avoidable accidents for one (Resident #1) of three residents reviewed for supervision.

On [DATE], CNA E failed to notify Resident #1’s charge nurse, the DON and Administrator when she returned the resident to her room after finding her outside without staff supervision.

On [DATE], CNA F failed to notify Resident #1’s charge nurse, the DON and Administrator when she returned the resident to her second floor room after finding her outside on a patio without staff supervision.

On [DATE] at 1:10 PM, Resident #1 was found outside on the pavement face down with no pulse. CPR was initiated and continued when EMS arrived. Her death was pronounced at 1:30 PM.

These failures resulted in a past noncompliance Immediate Jeopardy that occurred on [DATE] through [DATE] at a scope of pattern with actual harm. The facility had implemented actions that corrected the non-compliance prior to the beginning of the investigation.

This failure could affect three residents, who were identified by the facility as wanderers and/or an elopement risk by placing them at risk injury, harm or death.

The DON stated further the facility began an investigation on [DATE] which revealed Resident #1 was last seen around 10:00AM on [DATE], by nursing staff on the second floor near her room. Around 12:30 PM, the staff were passing lunch trays and noted Resident #1 was not in her room. The staff initiated the missing resident protocol and found Resident #1 outside on the sidewalk around 1:00 PM. During the investigation, she became aware of additional incidents of elopement by Resident #1 that had occurred in the days just prior to the incident on [DATE]. Two facility staff revealed that they witnessed Resident #1 outside of the facility after hearing the Wanderguard alarm sound on two separate occasions. Both facility staff re-directed the resident back inside to her room on the second floor. Both staff members denied reporting either incident to their immediate supervisor, Director of Nursing, or Administrator. The first incident occurred on [DATE] and the following incident occurred in the morning on [DATE] prior to Resident #1 being reported missing later the same day on a separate occurrence.

In an interview on [DATE] at 9:30 AM, the ADON A stated the Wanderguard alarm was working correctly on [DATE]. During the facility investigation residents revealed that they did hear the alarm go off, but could not provide specific details of regarding the time. All staff present during the incident involving Resident #1 missing on [DATE], denied entering the code in order to turn the Wanderguard alarm off. Residents that were present at the door that Resident #1 exited the building denied entering the code in order to turn the alarm off when Resident #1 exited the building. Follow up interviews were conducted with residents that stated they heard the alarms go off were not consistent with previous interviews. The facility would then have to change all the codes. The facility was in-serviced on being secure with the codes to exit the building.

Personal Note from NHA – Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.

You can make a difference. If you have a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately.

We can help you and your loved one file a state complaint, hire a specialized nursing home attorney or help you find a more suitable location for your loved one.

Contact us through our CONTACT FORM located on our website here below or on the sidebar or call our toll free hot line number: 1-800-645-5262.

You can make a difference even if your loved one has already passed away.

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