Westchester Meadows, a nursing home based in Valhalla, NY, drew a deficient rating from the Department of Health in a certification survey dated June of last year. The Department found that the facility failed to keep the resident environment as free of accident hazards as possible. Specifically, the report notes that Westchester Meadows failed to prevent a resident from wandering throughout the facility without staff supervision.
The resident discussed in the survey, an eighty-six year old woman, suffers from numerous conditions that would make her a wandering risk. Among these impairments are senile dementia, insomnia, and depressive disorder. In addition to being a wander risk, the patient also has physical impairments that would make her a risk for falls, including unsteady gait and poor vision.
On the night of the incident, the resident was found by a nurse on a separate floor. She had taken an elevator to an upstairs floor, where she had formerly resided, because she was expecting breakfast visitors. The elevator that the resident used is located next to a reception desk, however the desk is not staffed after 11:00 p.m. A nurse found the resident at approximately 2:00 a.m. When the nurse found the resident on the second floor, the patient did not have with her anything to assist with ambulation.
A facility must ensure that each resident receives adequate supervision to prevent accidents. The incident described in the Department of Health report highlights several of the dangers that can accompany unsupervised elderly residents with cognitive impairments. Fortunately the resident was found only a floor away from her room. With no security or staff stationed in the lobby, it appears that she could have eloped from the facility rather than simply take the elevator to a separate floor. Additionally, it would not, as it did not, occur to an elderly individual suffering from senile dementia to take some sort of ambulative assistance device when moving unaccompanied throughout the facility. For someone who suffers from unsteady gait and vision impairment, as did the patient in question, this forgetfulness could have resulted in a fall and potentially serious injuries that could result.
Perhaps the incident detailed by the Department of Health survey will lead to a greater degree of supervision and security at Westchester Meadows, particularly for elderly residents suffering from dementia. The entire certification survey, including a failure at Westchester Meadows to develop comprehensive care plans, can be found here.