State Findings:
Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure one (1) of four (4) sampled residents (Resident #1) received adequate supervision and monitoring to prevent elopement (exit the facility unsupervised).
Resident #1 had a history of wandering and exit seeking behavior, which increased in the evening. On 10/21/2020, the facility assessed the resident required a wanderguard (system used to monitor the resident’s location) due to the resident exhibiting behaviors of [CONDITION(S)], delusional behavior, and wandering that placed the resident at significant risk. On 11/18/2020, Resident #1 exhibited behaviors of wandering in other rooms and was redirected several times, however, the facility failed to increase the resident’s supervision.
On 11/18/2020 at approximately 9:50 PM, staff could not locate the resident in his/her room and noted the resident’s window was open and the window screen was gone. Resident #1 crawled out an unsecured window in his/her room and went to a neighboring hotel. The hotel was located behind the facility near a busy four (4) lane highway between (2) two intersections, in a high traffic area. The resident was last seen at the facility at approximately 9:10 PM and staff found resident at the hotel after 10 PM.
The facility’s failure to ensure adequate supervision/monitoring for a resident exhibiting exit seeking behaviors has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on 02/11/2021 and determined to exist on 11/18/2020. The facility was notified of the Immediate Jeopardy on 02/11/2021.
An acceptable Allegation of Compliance (AoC) was received on 02/22/2021. The State Survey Agency validated the AoC and determined Immediate Jeopardy was removed on 02/25/2021. The Scope and Severity was lowered to a D while the facility develops and implements the Plan of Correction (PoC); and, the facility’s Quality Assurance (QA) monitors the effectiveness of the systemic changes.
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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.
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Personal Note from NHA-Advocates
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