In an April, 2011 deficiency report, the Department of Health cited Hopkins Center for Rehabilitation and Healthcare, a Brooklyn nursing home, for the failure to maintain an environment as free of accident hazards as possible. Specifically, Hopkins failed to ensure that residents at risk for elopement were properly monitored. This failure led to the wandering and elopement from the facility of an 85 year old resident.
The breach of duty effected one out of a sample of seven residents in the DOH survey. The Department noted, however, that it had the possibility to affect a total of twenty-one residents of the Brooklyn nursing home. The resident who eloped suffered from dementia, among other physical ailments. In her Minimum Data Set (MDS) Assessment, the facility noted that the resident’s mental status was “severely impaired.” Due to this impairment, the nursing home deemed that she was an elopement risk, and ordered this risk factor to be incorporated into her care plan. In fact, the resident’s dementia extended to the point that, during a subsequent interview with the Department of Health, she stated that she still worked every day and returned to her home in the Bronx afterward. Despite the recognition that the care plan precaution be taken, the patient managed to leave the facility unaccompanied one afternoon. Several hours later, she was located at her former home wearing only pajamas (the incident occurred in late March). Ultimately, the resident was unharmed, but the failure of the facility to properly monitor her actions and well-being placed her in immediate jeopardy.
Per federal regulation, a facility must ensure that a resident receives adequate supervision to prevent accidents of any type, including wandering/elopement described above. Exacerbating the nursing home’s failure is the fact that the staff recognized this particular resident’s potential propensity for wandering off, yet somehow she managed to exit the home without staff supervision. The DOH report also notes that security personnel in charge of guarding exits were not properly trained to prevent such an elopement from occurring. Properly training these guards may have prevented this dangerous condition after the resident went unnoticed by the CNA’s on staff at the nursing home.
One need not be a doctor or lawyer to understand the risks associated with an elderly person suffering from dementia being allowed to wander from a care facility unsupervised, including falls, fractures, car accidents, etc. Fortunately in this case the resident was returned unharmed to the facility. This incident underscores the importance of developing, implementing, and maintaining proper and individualized care plans for each resident of a nursing home. Additionally, staff members of every sort must be trained to know the protocol for dealing with an elopement risk. Perhaps this incident will cause Hopkins to update its policies and procedures in the future to prevent another incident like this from taking place.