IDPH cited and fined the Villa at Windsor Park nursing home in Chicago after a resident there left the facility and was missing for 6 days.
There are a number of things which prompt families to decide to admit a loved one to a nursing home. One of these is when a parent or other family members wanders from home without supervision and is unable to return due to dementia or some other disease which affects their memory and/or thought process.
When a resident is admitted to a nursing home, they undergo a comprehensive assessment which is a part of the care planning process. Assessing the risk of elopement (or wandering from the nursing home) is a standard part of the assessment. Some of the risk factors for elopement include: being able to ambulate freely with or without an assistive device; a history of attempted elopement in the nursing home setting or wandering prior to admission; dementia; restlessness, anxiety, or agitation; and an expressed desire to go home or otherwise leave the facility.
When a resident is assessed an elopement risk, that must be addressed in the resident care plan. Three of the more common steps which are part of the care plan would include placing the resident in a loccked or restricted unit, use of an alarm called a wanderguard, and frequent rounding. The reason that this must be addressed in the resident care plan is because a nursing home resident who wanders from the facility is at risk of serious injury or death from due to being involved in an accident (such as a fall or being hit by a car) or the victim of a crime. Put simply, their physical and mental limitations leave them vulnerable.
The resident at issue had a history of wandering before being admitted to the nursing home, and the family told the staff this. They were assured that the resident would be placed in a locked unit. The resident was admitted to the third floor of the facility and an alarm was applied to him. Upon entry to the elevator, an alarm was supposed to sound. The staff told the surveyor that this was a silent alarm, but the director of nursing said that it wasn’t. When they tested the alarm, they found that it did not sound. The building’s maintenance director admitted to the state surveyor that he was checking off on maintenance logs that regular inspections of the alarm system were being done, but he had in fact not done any in a long time. In short, it appears that this facility did not have a fully working alarm system.
After leaving the facility, the resident was missing for a 6-day period which included two visits to hospital emergency rooms from which he was discharged, once to a homeless shelter. He was discovered by family six days after leaving the facility standing in the middle of a high traffic street.
There is a very basic set of steps that must be taken to address residents who are at risk of elopement, and having a working alarm system which alerts the staff that a resident is leaving a secure unit is on the front line. Obviously, this facility did not have a fully working system because no one was actually checking to make sure that it was functioning. This resident went missing during the month of June. Had an absence of this length happened in the dead of winter, it is doubtful that this resident would have survived expsoure to cold for that length of time or not gotten seriously sick. Past that, he was discovered in the middle of the street. Getting hit by a car while wandering is one of the foremost risks with residents who wander from a nursing home which is why this is a part of the standard admitting assessment when a resident enters a facility.
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