IDPH had cited and fined Integrity of Smithton nursing home after a resident wandered from the nursing home and was injured by the police.
“Elopement” is the technical term for wandering from the nursing home. Generally, the residents who at risk for elopement or wandering suffer from relatively few physical impairments but have significant cognitive or mental impairments. When they leave the nursing home, they are at risk for injury from falls, being hit by a car, being exposed to extreme heat or cold, or suffering injury from other people in the community.
The resident at issue suffered from dementia and schizophrenia with long-term and short-term memory loss. He was assessed as being at risk for elopement and an elopement care plan was put into place which called for checks on the resident every 15-30 minutes. Before the day of the incident, he has successfully wandered from the facility about five and half months earlier. The staff also documented him attempting to exit the facility five days before this incident.
On the day of the incident, he was last seen by the staff at approximately 2:00 a.m. walking around the dining room with another resident. At 4:47 a.m., am alarm went off at a home approximately 2.2 miles from the nursing home because the resident was attempting to enter the home. The homeowner called the police who responded to the scene. When the police arrived, the resident was walking through a nearby field next to a pond. When the resident failed to comply with the officers’ instructions to show his hands, the officers tackled him and took him to the ground. Another responding officer recognized the resident as living at the nursing home, so he was brought to the hospital for treatment. X-rays showed that he suffered a fractured skull.
The police officers in this case did nothing wrong. They responded to a call from a homeowner who described a dangerous situation – someone trying to get into her house. When the resident did not comply with their instructions, they used non-lethal force to bring the resident under control. Had they made a different decision or had the homeowner gone for a gun, this situation could have ended in tragedy. Even though this did not have the tragic end it could have, this situation demonstrates the potential for danger associated with the residents wandering from a nursing home: either the police officers or the homeowner could have used greater force in responding to the resident’s actions, the resident could have continued walking and fallen into the pond, and so much more.
The investigation of this incident showed that the staff last documented checks on the resident at 7 p.m. He was seen by the staff up and walking about the facility including by the front door through out the night. When the resident was found by the police, he had a jacket on. For a resident who was a known risk for elopement, him wearing a jacket should have led to closer supervision of the resident. Further, although the door was equipped with a door alarm, the alarm never sounded.
There is a long list of shortcoming in the care that this resident received. His elopement risk was addressed in his care plan, but the steps that were required were not being implemented at the nursing home as there was no documentation of the required checks and he was gone for as long as two hours before the homeowner called the police. Further, exit-seeking behaviors tend to be repetitive, and the fact that he had been attempting to leave just a few days earlier is something that the full staff should have been alerted to. Finally, devices such as door alarms are the fail-safe to prevent injuries and deaths from residents wandering from the facility. The citation did not establish why the alarm failed to sound, but a fail-safe must truly be a fail-safe to be effective.
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