IDPH has cited and fined Aperion Care West Ridge in Chicago after a resident jumped from a second story window, landing 20 feet below, then walked to a nearby lake and subsequently drowned to death.
Elopement is the technical term for wandering from the nursing home and is something that poses a serious risk to residents who do so. One of the basic factors driving a family’s decision to admit a family member to a nursing home is the fact that they are unable to keep a loved one safe at home. Sometimes that is due to the fact that they wander from home due to advancing dementia and confusion and are unable to make good decisions about how to keep themselves safe.
When a nursing home accepts a resident into their facility, there are a number of standard assessments which are done as part of the care planning process. One of these is assessment of elopement risk. Every facility has a slightly different tool for assessing risk of elopement, but there are three main risk factors that show that a resident is at risk for elopement: (1) confusion, a mental health disorder or dementia, (2) the ability to ambulate (someone is not a high risk for leaving the facility if they cannot get around reasonably well), and (3) either an expressed desire to leave (“I want to go home”) or a history of having left the facility or attempted to do so.
If a resident is at risk for elopement, then a care plan must be put into place which is tailored to the needs and behaviors of the particular resident. Frequently, this involves placing them on a locked unit so that they cannot easily leave the facility. Past that, it also usually includes regular, close supervision of the resident and either monitoring and/or alarming of exit doors and windows.
The resident at issue here was at risk for elopement. He suffered from schizophrenia, bipolar disorder, suicidal ideation, homelessness, and diabetes. He was also able to move quite well and often liked to get up and smoke.
While he was clearly at risk for elopement, the Elopement / Community Survival Assessment that was completed upon admission stated otherwise. The nurse that completed the form marked that the resident was not at risk for elopement and that he was not suffering from any severe mental illness. When confronted by the state examiner with this information, the nurse declared that she did not know why she did not mark the resident at risk for elopement. She admitted to making a mistake.
On the morning of the elopement, the facility staff discovered the resident was missing from his second floor room and a code pink elopement alert was initiated. The resident’s roommate reported to staff that he had witnessed the resident jump out of their shared window. The window the resident exited from had a broken mechanism that allowed it to fully open. This dangerously unsecured window was approximately 16-20 feet from the ground.
Sometime after the resident managed to elope out of this open window, he ended up in a nearby lake. Later in the evening around 7:00 PM, police arrived at the facility to inform the staff that the resident had been found and transported to the hospital. Records from the hospital show that the resident had sustained anoxic brain injury from drowning in the lake. Despite several days of medical interventions, the resident did not recover any brain function and was pronounced dead by neurological criteria by the intensive care unit physician and neurology doctor at the hospital.
The outcome in this case was dire. Residents who wander from nursing homes are at high risk for injuries from falls, from criminal assaults, and from exposure to the elements. If a resident is missing for an extended period of time, they will also not be receiving necessary medications and treatment. Nursing home residents need good care.
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