A Department of Health (DOH) study regarding the 2008 elopement of a 59 year old woman at Fieldston Lodge Care Center in Riverdale, NY found the facility’s measures to prevent such wanderings lacking. The patient, identified in the report as “Resident # 1,” entered the facility in November, 2007 with diagnoses ranging from Hypertension to paranoid Schizophrenia. Upon admission, the facility recognized that Resident # 1 was an elopement risk, both through its elopement risk assessment tool and the Comprehensive Care Plan. She was fitted with a wanderguard, among other standard interventions for elopement
Fieldston documented that Resident # 1 grew increasingly anxious about leaving the facility and returning home. Her score on the elopement assessment tool increased as well. Despite these warning signs, Fieldston implemented no additional interventions or monitoring. On August 16, 2008, Resident # 1 left the facility of her own volition. Not until August 19 did three staff members finally find the resident in her apartment building. Luckily, she was not seriously injured.
The Code of Federal Regulations and the NY Public Health Laws have very specific requirements to ensure the safety of residents and the prevention of neglect on the part of the facility. The Department of Health cited two relevant sections in its write-up of Fieldston. Title 42 Section 483.13(c) of the Code of Federal Regulations states that “[t]he facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.” Additionally, Title 42 Section 483.25(h) sets forth that: : “The facility must ensure that (1) The resident environment remains as free of accident hazards as possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents.” The DOH cited each of these sections in its deficiency report for Fieldston. In a situation fraught with risk as in the case of Resident # 1, the Department of Health demands that a certain standard of care be maintained by the facility with respect to the patient. In this case, the department obviously felt that this standard was not met.
Website Resource: Department of Health