On June 14, 2016, a 76-year-old woman with dementia wandered out of Citadel Rehab and Nursing Center in the Bronx, NY. She can be seen on surveillance video standing in the Center’s lobby and leaving the facility with a group of people. Rufus Dunbar, the woman’s son arrived for a visit to find out that his mother was not where she was designated to be. After notifying staff that he could not locate his mother, they searched everywhere, yet still could not find her. Not until facility video surveillance was reviewed, did they realize that Doris Dunbar had wandered right out the front door. Rufus desperately pleaded for any help to find his mother Doris and bring her home.
Earlier this year, The Citadel Rehab and Nursing Center at Kingsbridge received a citation for a similar incident of wandering/elopement. On February 17, 2016 the NYS Department of Health conducted a Survey based on a complaint. After the investigation, it was discovered that a resident had set fire to a room, eloped after setting the fire and was missing for approximately one hour. Neither incident had been reported to the New York State Department of Health. According to federal statute 483.13(c)(2), the facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency).
The NYS Department of Health performs investigations, known as surveys, of the quality of care and life of those residing in nursing homes throughout the State. These surveys are conducted every nine to fifteen months for purpose of certification, follow-up reviews, and for complaints or incidents reported to the DOH. Survey teams are comprised of multidisciplinary healthcare workers including nurses, nutritionists, social workers, pharmacists and sanitarians. During a standard survey, the quality of the care provided by the facility is reviewed. The survey team arrives unannounced and observes resident care, staff/resident interaction, and environment. Medical records and other documentation are also reviewed during the survey process. The healthcare facility can be found out of compliance when regulatory requirements have not been met and may be fined for each violation citation received. A plan of correction must be submitted and approved by the DOH before the facility is found to be back in compliance.