Norwegian Christian Home and Health Center, a nursing home in Brooklyn, NY, was cited for failing to ensure that residents received adequate supervision. Based on an inspection by the Department of Health on August 6, 2008, a 93 year-old male resident eloped (wandered) from the facility undetected through a door that failed to alarm and staff were unaware the resident was missing.
Although the nursing home’s care plan called for providing ID bands/pictures at security post, 15 minute visual checks and the use of a wander guard on the resident’s left ankle, the resident went missing at approximately 10:30 am. Fortunately, at approximately 1:00 pm, the resident was found sitting on a stoop in the neighborhood and was taken to the hospital. The resident resident was not wearing his ID bracelet and had not been observed by the nursing staff since 9:30 am (despite the need for 15 minute checks).
As a result of this incident, the Department of Health found that:
A. The facility failed to ensure that front desk personnel and security officers responsible for monitoring the door access system were trained regarding the purpose, function and operation of the system; and B. The facility failed to implement policies and procedures to ensure that facility staff provide supervision to residents who were identified as being at risk for elopement.
Luckily, the resident was not injured. However, the facility received the most serious type of citation (Immediate Jeopardy) due to the potential severity of injury to the resident.
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