State Findings:
Complaint # (AR 522) was substantiated, all or in part, with these findings:
Based on observation, record review, and interview, the facility failed to ensure adequate supervision was provided to prevent elopement for 1 (Resident #1) of 3 (Residents #1, #3 and #4) case mix residents who were at risk for elopement, as evidenced by failure to promptly care plan the resident’s elopement risk and failure to ensure the exit door alarm system was audible throughout the facility to alert staff when a resident attempted to exit or had exited the facility. The failed practice resulted in immediate jeopardy, which caused or could have caused serious harm, injury, or death to Resident #1, who exited the facility on 9/13/19 and was found by laundry personnel approximately 120 yards from the back door of the facility in the middle of a field, and had the potential to cause more than minimal harm to 14 residents who were at risk for elopement, according to a list provided by the Administrator on 9/18/19. The Administrator was informed of the Immediate Jeopardy on 9/18/19 at 4:57 p.m.
On 9/18/19 at 1:40 p.m., Laundry Employee #1 was asked about the elopement incident involving Resident #1. She stated, Me and another employee were driving in from that road. I was in my husband’s truck. I pulled up and she said, ‘is that someone over there?’ I said ‘where’? She (the resident) was really hard to see. She had on something red. That’s how I saw her. Then two nurses came out to go get her. I asked her which door she left out of and, of course, she was crying and confused. She didn’t know.
On 9/19/19 at 3:36 p.m., CNA #4 was asked about the elopement incident involving Resident #1 on 9/13/19. She stated, I was working West Short (Hall) by the Therapy door. I was up and down Short Hall and feeding people. She was asked if she heard any alarms. She stated, No ma’am. She was asked if she heard the alarm that sounds at the Nurse’s Station. She stated, No. She was asked how she would know someone had gotten out if she can’t hear the door alarm. She stated, That’s a good question.
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NHAA is here to assist families, residents, and the community by sounding the alarm on issues like those found above. This nursing home and many others across the country are cited for abuse and neglect.
If you have or had 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 have helped many already and we can help you and your loved one as well by filing a state complaint, hiring a specialized nursing home attorney or helping you find a more suitable location for your loved one.
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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.
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