IDPH has cited and fined Alden Long Grove nursing home after a resident wandered from the facility on March 7 only to be discovered over two miles away walking through a busy intersection during the pre-dawn hours.
The resident at issue suffered from Huntington’s Disease which caused him to experience delusions. He also suffered from cognitive impairments, and was not steady with walking and required assistance with mobility. On March 1, he demanded to go home with his family and pushed his mother in an effort to get out the front door of the facility. On March 2, he was assessed as being at high risk for elopement, or wandering from the facility unsupervised and he was placed on 1:1 supervision. He again expressed a desire to leave the facility on March 4. On March 6, the 1:1 supervision was terminated in favor of checks every 15 minutes. However, the staff admitted to the surveyor the 15 minutes checks could not always be performed because they were caring for other residents.
At approximately 4:30 a.m. on March 7, another resident who was playing with his phone in the front lobby saw the resident at issue walk right out the front door of the facility. The resident alerted staff members who checked the interior and exterior of the building for the resident and then called police. The staff member assigned to care for the resident at the time said that he last saw the resident at 4:00 a.m. The police received a call reporting seeing a man walking through a busy intersection over 2 miles away and sent a patrol car. It was the missing resident and he was brought back to the facility before being brought to the hospital for examination due to exposure to the cold. The resident told the reporting officer that he had fallen backwards while he was out and hit the back of his head and that he wanted to got his home in Round Lake Beach, some 17 miles away. The surveyor described the route to the point where the resident was picked up by police as being filled with heavy traffic, ice, uneven ground, and road construction.
The hazards that this resident was exposed to underlines why avoiding incidents with elopement or wandering from a nursing home is so important. Along the way to the point where he was picked up by police in a busy intersection, the resident actually fell (and fortunately avoided severe injury like a hip fracture or a brain bleed) and was at risk for getting hit by a car the entire time. Due to the length of time that he was outside in below freezing temperatures, he was at risk for developing pneumonia, frostbite, or hypothermia, all of which can turn out be deadly conditions for nursing home residents.
So – the question is, how did this come to pass? There are at least three explanations:
1. The 15 minute checks which were not in fact done. The staff member assigned to care for the resident told police that he last saw the resident at 4:00 a.m. and was not aware that the resident was gone until sometime after 4:30 when another resident told him that the resident at issue went out the front door. This means that at least 2 checks were skipped, which raises an issue as to whether there was understaffing at this nursing home.
2. The 1:1 supervision was likely terminated prematurely in favor of the 15 minute checks. When a resident is actively verbalizing an intent to leave the facility and is acting on it, there is a high risk that the resident will in fact exit the facility with all of the risks that go along with that.
3. The front door alarm was disarmed. The investigation revealed that the facility had a front door alarm that was supposed to be armed when the front desk receptionist left for the day at 8 pm. Another resident had been out on pass and returned at 12:30 a.m. A nurse let her back into the building and failed to re-arm the alarm, so that when the resident at issue went out the front door, the alarm did not sound. When the safety of residents depend on staff supervision of the residents, there is always a risk of a breakdown which must be addressed by passive devices such as alarms. They act as a safety net for the residents. When the alarms are disarmed, the necessary safety net disappears.
This was a highly preventable incident which could have had a much more tragic outcome. The fact that it didn’t was good luck, not good care. Relying on good luck is no substitute for providing proper care.
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