IDPH cited and fined the Good Samaritan Society nursing home in Mt. Carroll after a resident wandered from the facility and suffered a heart attack.
One of the common reasons that families make the decision to admit a loved one to a nursing home is that they are suffering from a form dementia and have been known to wander and either get lost or put themselves in dangerous situations. In the nursing home industry, this form of wandering is known as elopement, and it is a serious threat to the health and well-being of the resident.
The resident at issue was admitted to the nursing home with his wife shortly before the incident which resulted in the citation. He suffered from dementia, but did not need assistive devices, and had a known history of wandering. During his first few days in the facility, he was seen pushing his wife around in her wheelchair. There were attempts that were documented to leave the nursing home – once by leaving through an exit door which was alarmed with a wanderguard and once by attempting to leave through the front door with a group of visitors.
The resident was properly assessed as a fall risk, and staff members interviewed in connection with this incident acknowledged that they needed to keep an eye on him.
On the day of the incident, staff saw him walking up and down the halls wearing a fall weight jacket, a sweatshirt, and shoes. He went into an unoccupied room, opened up the window, and popped the screen out. He climbed out the window and walked away from the facility. Once the staff realized that he was not in the building, the director of nursing was contacted, and she pulled up security video from her home computer and saw the resident going into the unoccupied room and not leaving. Staff entered the room, saw the window open and footprints in the snow leading away from the building. The staff called 911.
He was located by the sheriff’s department approximately two and a quarter hours after he was last seen, trying to climb a fence on a farmer’s field a short distance away. He was brought to the hospital where he was diagnosed as suffering from hypothermia and had suffered a cardiac injury which the doctor believed was due to he exertion associated with leaving the facility and walking that distance.
This is a situation which could have had a far worse result as it is not hard to envision a set of circumstances where the resident might have fallen and suffered a fractured hip or ended up suffering a wrongful death either from accidental injury or from simple exposure to the cold.
The nursing home did some things right: they properly recognized that this resident was an elopment risk and they put a care plan into place to address the elopement risk. Their shortcoming was in allowing him into an area where he would not be supervised given that he made at least two active attempts to leave the facility during the very short period of time he was in the nursing home before this. The other area was in the failure of the staff to address the fact that the resident was up with a coat on for outdoors before 6:00 a.m. The staff was well aware by that time that he was a risk for elopement and his dress at that time of day should have caused more concern than was in fact generated.
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