State Steps In After Second Episode Involving Patient Elopmement At Same Facility

I think its downright scary when facilities fail to learn from their mistakes.  Of course, --- any person, --- any facility can make a mistake one time, but when the same errors are repeatedly made I feel there is well deserved cause for concern.

An episode of a patient wandering from Brentwood Assisted Living facility, would normally not be a particularly noteworthy event--- especially since the eloping woman will hopefully recover from her injuries.  What deservedly brings more attention to this incident is the fact that this was the second patient to wander from this facility this year!

In the most recent occurrence, the Michigan Department of Human Services is investigating the incident in which a 91-year-old woman wandered from the assisted living facility with her walker.  Three days later, the woman was discovered by neighbors in the area at the bottom of a heavily wooded ravine. 

As DHS investigates this incident, just months before the agency investigated a similar incident in which a patients eloped from the facility.  After the agencies investigation, it was revealed that Brentwood: 1) failed to monitor the patient in accordance with their care plan that identified them as being at high risk for eloping and 2) failed to timely notify the patients family of the occurrence.

Patterns of poor care

Of course, episodes of poor care should give rise to concern.  However patterns of poor care really should give rise to alarm both on the part of families who have loved ones at this facility and on the part of the state.

Even though it appears that neither patient involved in these elopement events was injured seriously, I hope that the state recognizes the severity of these lapses in patient care and reprimands the facility accordingly. 

Episodes involving patient elopement and wandering rarely end as well as it did for these patients.  Unfortunately, when patients wander from a nursing home or assisted living facility they are ill-equipped to deal with the world around them.  In our nursing home abuse practice, we have worked on several cases where patients received severe injuries or were killed after they left the safe confines of their facility.

Read more about this case of elopement from an assisted living facility here.

Elopement

Assisted living and nursing home patients with dementia and Alzheimer's are commonly known to elope from their facilities. On admission, the facility should conduct an assessment of the patient (with family if possible) and determine the persons risk level for eloping from the facility.

Once an assessment has been completed, the implementation of simple preventative measures implemented by a facility to assure the patient remains safely at the facility.  Assisted living facilities and nursing homes that care for patients who are at risk for eloping should have the following safeguards in place:

  • Door alarms
  • Window locks
  • Door locks
  • Bracelets that track each resident's location
  • Hire adequate staff to look after residents
  • Have contingent plan to locate patients in the event a resident elopes from the facility

Related Nursing Homes Abuse Blog Entries

Assisted Living Facilities Need To Re-Evaluate If They Are Capable Of Caring For Dementia Patients

Chicago Nursing Home Lawyer, Jonathan Rosenfeld, Interviewed Regarding Preventing Patients From Wandering From Their Facilities

Three Employees At Assisted Living Facility Disciplined For Their Failure To Report Missing Nursing Home Resident

What Can Nursing Homes Learn From Jails?

Nursing Home Negligence Lawsuit Filed After Man Wandered From West Virginia Facility

Assisted Living Facilites Need To Re-Evaluate If They Are Capable Of Caring For Dementia Patients

Many assisted living facilities and other nursing home alternative facilities have done very well financially--  playing into the stigma associated with nursing homes that many people hold.  While nursing homes may receive a fair amount of bad press, they provide essential medical services for millions of patients. 

The level of care offered at assisted living facilities simply is not intended to take the place of the skilled nursing care offered in nursing homes.

Unfortunately, I've seen too many assisted living facilities fail to accurately inform families about the limitations in care that they offer.  In most cases, it is up to the assisted living facility to inform families about the type of care they can provide and to do an assessment of each patient's realistic care needs.

I feel strongly that assisted living facilities have an implicit duty to advise families if they can not care for their loved ones.  By accepting and retaining a patient, the facility implies that they are capable of safely caring for the person.

Over the years, I've seen the line distinguishing patients who require skilled nursing care provided in a nursing home vs. non-skilled assistance provided at an assisted living facility get blurry-- very blurry especially with patients who are particularly reliant on facilities for most of their daily living needs.

Many dementia patients require extremely high levels of care, yet many assisted nursing facilities (alf's) insist that they are capable of caring for them. 

The ability of assisted living facilities to care for an dementia patient will likely get called into question after 90-year-old man (with dementia) wandered from a Sierra Oaks Assisted Living facility in Pennsylvania.  Ten days after the man wandered from the facility, police located the man's body.

Could this have happened in a nursing home?

Of course.  Unfortunately, nursing home patients wander from facilities fairly frequently.  However, nursing homes are more likely to have staff in place and specialized equipment than assisted living facilities.

Situations, such as the wandering incident above, really should force families to re-evaluate the best living arrangements for their loved ones.

Related Nursing Homes Abuse Blog Entries:

Woman Dies From Hypothermia After Wandering From Assisted Living Facility

Family Sues Florida Nursing Home For Death Of Wandering Resident

Man Wanders 20 Ft. From Chicago Nursing Home To His Death

How Much Freedom Should Assisted Living Facilities Give The Mentally Disabled?

Elderly Woman Wanders From Her Convalescent Home To Her Death

I'll never get accustomed to the fact that many elderly will suffer an injury or die due to the carelessness of people who are intended to care for them.  It seems that every few weeks we hear about an elderly person who mysteriously goes missing from a facility and wanders to his or her death.  Despite the frequency, it still outrages me when I hear about such completely preventable situations.

Most recently, I was saddened to hear about the death of 63-year-old Rosemary Nelson who was found dead along the shoulder of the road after wandering from a California convalescent home.  Ms. Nelson's body was discovered three days after she was reported missing from the facility that was responsible for her care.  A medical examiner concluded Ms. Nelson's death was due to 'exposure'

According to a report from Ms. Nelson's family, Ms. Nelson had a history of wandering from facilities and had gone missing from other board-and-care facilities in the past.

Of course its easy to come up with excuses why this elderly woman managed to wander from this skilled nursing facility, yet the reality most certainly remains that someone at the facility was not doing their job when this lady managed to leave undetected.  As a society we must begin to demand that nursing homes begin to look after our elders the same way we expect nursery schools to look after out toddlers.  Until we demand full accountability, we will likely continue to hear about elderly who wandered into a world they are ill equipped to handle.

Read more about this wandering episode involving a California Nursing Home here.

Related Nursing Homes Abuse Blog Entries:

Assisted Living Facility Lets Resident Walk Out The Door & Into Semi

Woman Dies From Hypothermia After Wandering From Assisted Living Facility

Chicago Nursing Home Lawyer, Jonathan Rosenfeld, Interviewed Regarding Preventing Patients From Wandering

What Can Nursing Homes Learn From Jails?

Chicago Nursing Home Lawyer, Jonathan Rosenfeld, Interviewed Regarding Preventing Patients From Wandering

Nursing home lawyer, Jonathan Rosenfeld, was recently interviewed for an article on preventing patient wandering.  The article 'Prevent Wandering Patient Tragedies' appeared in the on-line edition of Healthcare Technologies Online, can be viewed here.

Wandering Nursing Home Patients

Many nursing home patients with dementia and Alzheimer's are prone to wander from the facility. Once out of the safety of the nursing home, these vulnerable people are particularly susceptible to injury.  

Simple preventative measures implemented by a facility could literally be the difference between life and death for nursing home patients. There is no excuse for a nursing home's failure to keep residents who are prone to wandering from leaving the premises of the facility.

Nursing homes that care for patients who are prone to wander or elope should have the following safeguards in place:

  • Door alarms
  • Window locks
  • Door locks
  • Bracelets that track each resident's location
  • Hire adequate staff to look after residents
  • Have contingent plan in case a resident does wander from the facility

Related:

Alzheimer's Patient Wanders From Texas Nursing Home To Her Death

What Can Nursing Homes Learn From Jails?

Family Sues Florida Nursing Home For Death Of Wandering Resident

Can Assisted Living Facilities Adequately Care For Alzheimer's Patients?

Is it fair to expect an assisted living facility-- loosely regulated entities that help residents with daily living activities to care for a person with Alzheimer's?  Assisted living facilities (ALF's) are intended to provide a semi-structured environment to (primarily) elderly group.  Meals are prepared and staff are intended to provide residents with daily living activities.  Unlike nursing homes, ALF's are not intended to provide skilled nursing care.

In the case of Alzheimer's patients, many ALF's accept these people despite the fact that many offer no specialized care for them.  Is this a case of corporate greed putting its quest for profits ahead of providing necessary care to its residents?

In the case of Ruby Larson (an Alzheimer's patient), I think the answer is a resounding 'yes'.  On July 23, 2007 Larson wandered from Pheasant Pointe Retirement and Assisted Living Residence-- never to be heard from again.  Last year a judge declared Larson to be legally dead as the search for her was fruitless.

Ms. Larson, 75, was admitted to Pheasant Pointe in May, 2007 suffering from dementia, memory loss, and disorientation.  During the three months Larson was a patient at Pheasant Pointe, she wandered from the facility three separate times.

Larson's family filed a lawsuit against Pheasant Point and its parent company, Spectrum Retirement Communities of Oregon claiming the staff failed to properly supervise Larson and that the companies should have known that Ms. Larson required care only a specialized Alzheimer's care unit could provide.

Unfortunately, Alzheimer's patients may encounter many problems while living in an assisted living environment.  Of course, depending on the individual facility, the levels of care may be different.  But most ALF's are horribly ill-equipped to care for Alzheimer's patient who typically require great care with meals, getting about, re-direction, medication as well as maximum assistance with daily living.

If a facility is unable to provide the level of care required, the facility should advise the family.  Too often, ALF's never mention to the family that their loved one may be better off in a nursing home or alternative facility that specialized in Alzheimer's care.  

Read more about this lawsuit against an assisted living facility here

Related Nursing Homes Abuse Blog Entries

The Truth Revealed: Nursing Home Tries To Cover-up Fact That Resident Choked To Death On Tuna Sandwich 

Nursing Homes For Alzheimer's Patients. What To Look For?

Woman Dies From Hypothermia After Wandering From Assisted Living Facility 

Alzheimer's Patient Wanders From Texas Nursing Home To Her Death

 

Authorities are now looking into how 85-year-old, Edna May Sides, managed to wander from Hillside Plaza Nursing Home without the knowledge of nursing home staff.  On July 15th, Sides dead body was found a short distance from the facility.   

Initially, the nursing home told the family that Sides passed from 'natural causes'.  However, when the family learned that Sides wandered from the facility, they notified the Cherokee County Sheriff and the Wells Police Department. "The family thought it was a little strange, so they went to the Justice of the Peace in Alto and then called the Sheriff's Office and our department." said Wells Police Chief Barry Starnes
 
Despite the fact that law enforcement officials are involved in an investigation, Chief Starnes doesn't believe foul play is involved, "I believe there was possible negligence, but I don't believe someone purposely did this. We're trying to get to the bottom of how this person got outside when she wasn't supposed to be," he said.
 
Read more about the wandering of a Texas nursing home patient here.
 
Wandering Nursing Home Patients
 
Once again, simple preventative measures implemented by a facility could literally be the difference between life and death for nursing home patients.  There is no excuse for a nursing home's failure to keep residents who are prone to wandering from leaving the premises of the facility.  Nursing homes that care for patients who are prone to wander or elope should have the following safeguards in place:
 
    * Door alarms
    * Window locks
    * Door locks
    * Bracelets that track each resident's location
    * Hire adequate staff to look after residents
    * Have contingent plans to locate residents who may wander from the facility
 
If you have loved one who may be prone to wandering from the facility, ask the administrator if the above safety measures are in place at the facility.  My guess is that facilities that implement these safety measures have significantly lower rates of wandering.

 

Three Employees At Assisted Living Facity Disciplined For Their Failure To Report Missing Nursing Home Resident

An investigation into the death of a 93-year-old man at a New York assisted living facility revealed that three employees at the facility acted improperly when they failed to document that the man was missing from his room.  Turns out-- the man had either jumped or fallen to his death from his second floor room.  The incident occurred on February 17th at Dosberg Manor, part of the the Weinberg Campus.  The man's dead body was discovered the following day on the ground outside his room.

An investigation into the death by the New York Health Department determined employees at the facility acted improperly in the hours following the man's death.  The following omissions were noted in the department's report:

  • At 9:40 that evening an employee was called into the man's room by his roommate to shut an open window.  Despite the fact that the employee noticed the man's glasses and a walker parked adjacent to the open window, the employee failed to look further into the man's whereabouts and lied to investigators about seeing the man in his room.
  • At 11:00 p.m. another employee at Dosberg failed to investigate the fact that the man was missing from his room, choosing to assume that man was in a hospital.
  • A third employee who made midnight rounds noticed that the man was missing-- yet failed to notify authorities.
  • Medical records indicate that staff helped the man take his medication at 6:30 a.m. on February 18th although by that time the man's dead body had been outside for over 11 hours.

As a result of the Department's findings, a new policy has been implemented by Dosberg Manor to ensure the whereabouts of all residents and the employees who were involved in the errors cited above will be disciplined.

Read more about the investigation of this missing nursing home resident here.

Nursing Homes Abuse Blog Posts On Missing Nursing Home Residents

Nursing Home Negligence Lawsuit Claims Sunrise Senior Living Failed To Supervise Resident During Field Trip

What Can Nursing Homes Learn From Jails?

Police Dog Finds Resident Who Went Missing From Chicago Nursing Home

What Can Nursing Homes Learn From Jails?

Why in the world would I suggest the the people who are responsible for the care of our most vulnerable take a lesson from those responsible for most violent?  The answer has to do with how nursing homes keep track of their residents. 

Call it wandering, eloping or just escaping, there have been several recent reports of nursing home residents who have wandered from their facilities to their death without the facilities knowledge.  When nursing home residents leave their safe and familiar facilities that are at the mercy of a world unaware of each residents needs.  Two recent cases highlight the need for nursing homes to take notes from the jails in the way they monitor residents, staff their facilities and implement basic safeguards to minimize the risks of missing residents.

In Chicago, 89 year-year-old Sara Wentworth was a resident at The Arbor of Itasca, a Chicago-land nursing home when she walked out a door and into a wooded area.  Hours later, staff found Ms. Wentworth's dead body just a short distance away.  

A investigation into the matter by local police concluded that personnel had last checked on the woman at 3 a.m. and area police were notified at 5:40 a.m. when the patient was lying on a gurney not breathing.  Nursing home workers acknowledged hearing the door alarm that was activated when Wentworth left the facility but took no responsive action.

In Ohio, an 87-year-old resident wandered from her facility and into a nearby road where she was struck by a hit-and-run driver.  The woman's body was found on the side of the road by local drivers. The woman had similar wandering episodes prior to this incident.

Both of the above situations involve residents who suffered from dementia. Yet despite the facilities diagnosis of dementia and their known propensity to wander, staff at these facilities failed to implement preventative measures and have adequate staffing to monitor these women and prevent them from harming themselves.

Perhaps the nursing home administrators should take a page from the wardens and other administrative staff of our correctional system?  An out of place inmate poses a risk to other inmates in the jail and to the public at large. In a jail setting, an inmate who is known as an escape risk will also likely get increased supervision.

Am I suggesting that nursing home residents be stripped of their rights to the same extent of violent criminals?  Of course not.  However, in the case of residents who are at risk of 'leaving the facility' some of the same escape precautions should be implemented. 

Put away the guns and striped uniforms, but keep in mind the following:

  • Assess all residents who are at risk of leaving the facility
  • Keep door alarms and window alarms should be installed and in working order
  • Staff should monitor all exits of the long-term facility or nursing home
  • Keep at-risk residents close to a nursing station or in a high-traffic area to assure many people on the nursing home staff can look after the resident
  • Potentially use physical restraints for residents who are at risk for harming themselves
  • Notify authorities immediately after residents are noticed missing
  • Have contingent plans in effect locate missing residents

Woman Dies From Hypothermia After Wandering From Assisted Living Facility

An 87-year-old woman froze to death after walking out of the secured Alzheimer's unit at an Ohio nursing home.  Dortha Gifford was a resident at the Heartland of Woodridge assisted living facility for the last five years.  Gifford lived in the locked unit of the facility because of her propensity to wander. According to Gifford's family, she had gotten out of the assisted living facility on other occasions. 

Why do these tragic themes of missing nursing home residents continue to emerge across the country?  Unfortunately, the answer is not singular.  Nursing homes consistently break the trust families place in them when they fail to:

  • Install technology updates (such as automatic locks and alarms) to their facilities that to help contain residents with a propensity to wander.
  • Train staff to identify residents who are likely to wander from the facility and how to search for missing residents.
  • Provide adequate staffing levels to look after residents.  Many of the wandering incidents occur during 'off' hours when the facility is minimally staffed.

If your loved one has escaped from a nursing home or assisted living facility, the facility is likely responsible.  We have helped many families recover civil damages for the death or injury of their loved one.  More importantly, many of the nursing home cases Strellis & Field prosecute have led to safety improvements at many facilities and help ensure the safety of new residents.

Related Nursing Homes Abuse Blog Posts On Resident Wandering:

Fall Leaves Dementia Patient With Broken Neck At Assisted Living Facility

Nursing Homes For Alzheimer's Patients.  What To Look For?

Family Sues Florida Nursing Home For Death Of Resident Who Wandered From Facilityy

How Much Freedom Should Assisted Living Facilities Give The Mentally Disabled?

Criminal Charges May Be Brought Against Chicago-Area Nursing Home In Connection To Resident's Death

Investigators from the Itasca Police Department and the Illinois Department of Public Health are looking into the recent death of an Alzheimer's resident in a Chicagoland nursing home.  Sara Wentworth, an 89-year-old woman was found death a short distance from door at the The Arbor of Itasca.  Nursing home records indicate that personnel had last checked on the woman at 3 a.m. and area police were notified at 5:40 a.m. when the patient was lying on a gurney not breathing. 

DuPage County Coroner Peter Siekmann said Wentworth had been outside for at least 90 minutes before a nursing home worker found her and brought her back inside. Nursing home workers told police they heard an alarm sounding from a door leading to the courtyard.  However, when staff attempted to look into the situation, they did not see did not take any further action.

Wentworth's daughter, Catherine Shain, said police had told her that her mother had gotten through two sets of doors and walked about 100 yards to the area where her body was found.  Despite the fact Wentworth required a walker to get around, no walker was found by her body.

The DuPage County, Illinois State's Attorney's office will evaluate the evidence surrounding this matter and determine if criminal charges are warranted against the nursing home or individual employees. Read more about the death of this Chicago-area nursing home resident here.

How can a nursing home worker can ignore door alarm?  This really is no different that a worker ignoring a call light or an alarm on a ventilator.  This act goes beyond negligence and certainly reaches the level of a willful disregard for the safety of residents.  No word yet on any disciplinary action taken against the lazy nursing home employee(s)....

Read more about the death of this Chicago-area nursing home resident here.

Related Nursing Home Abuse Blog Posts

Man Wanders 20 Ft. From Chicago Nursing Home To His Death

Nursing Home Negligence Lawsuit Brought After Man Wanders From Facility

Elopement

Family Sues Florida Nursing Home For Death Of Wandering Resident

The family of a 68-year-old nursing home resident who wandered from the facility to his death, has filed a nursing home negligence lawsuit.  The family of Antoine Saintil recently filed the lawsuit against Broward Institute For Long Term Care after Antoine want missing from facility on Christmas day.  Search efforts by the facility to find Antoine were unsuccessful.  By the time authorities found Antoine in a waterway, two miles from the facility, he had apparently drowned. 

Antoine Saintil's family faced a difficult decision that many families face every day when they placed him in the Florida nursing home--less than a month prior to his death.  However, the family realized a recent stroke left Antoine disoriented and beyond their ability to care for him. "Because my dad was sick and we didn't want to keep him in the house.  He needed health-care.  He needed someone to help him like doctors, nurses and therapist," said daughter Julie Saintil.

There is no excuse for a nursing home's failure to keep residents who are prone to wandering from leaving the premises of the facility.  Nursing homes that house people, such as Antoine, who are prone to wander or elope should have the following safeguards in place to ensure the safety of each resident:

  • Door alarms
  • Window locks
  • Door locks
  • Bracelets that track each resident's location
  • Adequate staff to look after residents
  • Have contingent plans to locate residents who may wander from the facility

There is no obligation on the part of nursing homes to house every person who seeks out the facility's services.  However, when the nursing home agrees to house a resident who is disoriented or has dementia, the nursing home is implicitly agreeing they are able to properly care for the individual and is responsible for providing proper care.  Read more about this wrongful death lawsuit here.

Nursing Home Negligence Lawsuit Filed After Man Wandered From West Virginia Facility

The family of a man suffered from dementia and has filed a wrongful death lawsuit against the nursing home responsible for his care.  The man was killed after he was struck by a CSX train.  The lawsuit names Heartland of Charleston nursing home and its parent company Health Care and Retirement Corp. of America LLC.  The lawsuit alleges the nursing home failed to:

  • Provide adequate supervision to the man
  • Follow facility protocols for missing residents
  • Secure the facility
  • Failed to use security cameras on the property to locate the man

The lawsuit highlights the tragedy that may result if a nursing home fails to monitor its Alzheimer's and dementia residents.  Nursing homes should not only identify residents who are prone to wander, but also have safeguards in place to keep individuals safely within the confines of the facility.  Nursing homes housing residents with dementia and Alzheimer's should have: door locks, window locks, security alarms and extra staff to ensure the residents remain safe and under supervision.  Read more about this wrongful death lawsuit here.

Man Wanders 20 Ft. From Chicago Nursing Home To His Death

 The Chicago Sun Times reported the sad story of a 72-year-old nursing home resident who wandered 20 feet from the facility to his death.  The man was a resident at Robbins Supportive Living, 13820 South Utica, was last seen by staff at the nursing home on October 22nd.  More than two weeks later, authorities discovered the man dead, laying face down in the marshland, a mere 20 feet from the facility.  

Did this nursing home even bother looking for the missing resident? 

How Much Freedom Should Assisted Living Facilities Give The Mentally Disabled?

A mentally and physically disabled woman walked out of an Maple Crest Manor, an assisted living facility in St. Louis, MO,  and unknown to the facility boarded a bus to Chicago, IL.  The woman left the assisted living facility for what the staff suspected would be 'a long walk'.  After several hours passed without sight of the woman, the facility contacted the woman's legal guardian who then alerted police.

Chicago police called local Missouri authorities after finding the woman's name on the national database for missing and endangered people.  The woman was brought by authorities safely back to the facility in St. Louis.  No charges were filed against the assisted living facility or the legal guardian.  

Authorities report the woman has the mental capacity of a 7-year-old.  This begs the question: Would you let your 7-year-old walk around unsupervised?  Clearly, this incident should have been prevented with the adoption of a more restrictive leave policy for residents.  

Read the full story regarding this incident involving elopement at an assisted living facility here.

Assisted Living Facility Lets Resident Walk Out The Door & Into Semi

An 81-year-old assisted living resident walked out the front door of the Bluffview Meadows facility in Wisconsin an into the lanes of a nearby highway where she was struck and killed by a semi-truck.  What makes this story particularly tragic is that this is the second incident involving resident elopement with two weeks.  Nursing homes and assisted living facilities must monitor the whereabouts of their residents.  Further, facilities must have adequate safeguards in place such as door alarms, locks and adequate staffing to prevent resident elopement.

Wandering


"Wandering' refers to a cognitively impaired person moving about a nursing home or long-term care facility aimlessly and without appreciation for what he or she is doing.

A nursing home resident's propensity to wander should be identified in an initial care plan.  Residents who are most likely to be wanderers are those who suffer from dementia, Alzheimer's or who may be heavily medicated.  Most frequently a nursing home resident who wanders, falls and gets injured.

It is up to the nursing home staff to provide a safe and secure environment for all residents.  In the case of a nursing home resident who wanders and receives injuries, the nursing home most likely did not:

  • Provide an adequate number of staff to supervise residents
  • Train nursing home staff on how to identify wanders
  • Train the nursing home staff on how to supervise the nursing home residents
  • Did not use bed, wheelchair or door alarms
  • Re-direct the nursing home resident to another activity

Elopement

'Elopement' is when a nursing home resident leaves the nursing home itself without staff knowledge and gets into harms way. 

Elopement in nursing homes is most common amongst residents who suffer from dementia, Alzheimer's Disease, and who are on medications (psychotropic drugs) that cause confusion.  In order to prevent situations where a resident may elope, it is important for the nursing home to conduct an assessment for every resident.  Assessments should trigger the nursing home staff to take precautions.

If a nursing home resident is determined to be a risk for wandering, the following precautions should be in place:

  • Door alarms and bed alarms should be installed and in working order
  • Staff should monitor all exits of the long-term facility or nursing home
  • Keep at-risk residents close to a nursing station or in a high-traffic area to assure many people on the nursing home staff can look after the resident
  • Potentially use physical restraints

Incidents of elopement often occur with residents who are the most vulnerable to injuries.  Below you will find some recent articles referencing injuries that have occurred following elopement.