**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility’s policy, it was determined the facility failed to provide supervision to prevent accidents and elopement for one (1) of six (6) sampled residents (Resident #1). On 09/03/18, at approximately 10:48 PM, staff heard the dining room exit door alarm sounding, responded to the alarm, but failed to look outside the facility to ensure a resident had not exited the building. The staff member who turned off the alarm was unaware that Resident #1 (assessed to be at risk for elopement) was outside the facility. An off-duty staff member was walking down the street, heard the resident yell, and found Resident #1 lying in a shallow ditch across the street from the facility. The off-duty staff member assisted the resident across the street and at approximately 11:22 PM, thirty-four (34) minutes after the door alarm sounded, called the facility to notify them that Resident #1 was outside. Facility staff assisted the resident back inside the facility and assessed the resident to have small abrasions to the elbow and knee.

In addition, the facility failed to ensure supervision was provided to prevent falls for Resident #1. The facility failed to determine the root cause of the resident’s falls and implement interventions based on the risk factors. Further, the facility developed an intervention to supervise Resident #1 every fifteen (15) minutes; however, the facility failed to implement this intervention and Resident #1 sustained thirty (30) falls with no significant injury from 06/26/18 through 09/13/18.

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 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. 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.