State Findings:
Based on observations, interviews, record review, and review of the facility policy titled, Occurrences, and review of the policy Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property the facility failed to protect one of eight sampled residents, R#1, from neglect by not making observations of R#1 throughout one shift during which time R#1 eloped from the facility undetected. The elopement of R#1 was not identified for 10.5 after the last documented observation.
On September 27, 2021, it was determined the facility’s noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents.
The Administrator and Regional Nurse Consultant were informed of the Immediate Jeopardy (IJ) on September 27, 2021, at 11:48 a.m. The noncompliance related to the IJ was identified to have existed on September 18, 2021, when staff failed to determine that R#1 was missing from the facility for 10.5 hours, until a family member arrived to visit and the resident’s elopement was discovered.
Interviews with CNA DD and Registered Nurse (RN) CC, who worked the Night Shift, 7:00 p.m. to 7:00 a.m. (7P-7A) revealed CAN DD never saw R#1 after 12:00 a.m. on 9/18/2021 and RN CC revealed she arrived late for her shift and never saw R#1 during her work hours of 12:33 a.m. until 6:58 a.m. on 9/18/2021, even though RN CC signed off as giving the resident’s 6:00 a.m. medications which were left on the resident’s bedside table.
Interview with the assigned Detective from the local police precinct revealed the police located R#1 between 2:30 p.m.-3:00 p.m. on 9/18/21 at a local hotel approximately four miles from the facility. She was unharmed and declined medical attention.
There was no evidence any facility staff observed R#1 or identified that R#1 was missing from the facility for 10.5 hours.
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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
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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