IDPH has cited and fined Aperion Care of Forest Park nursing home after a resident there wandered from the facility, fell in a nearby river, and drowned. The body was found six days later and was not identified for another five days after that.
“Elopement” is the technical term for wandering from a nursing home. It is a highly hazardous situation because once the resident leaves the nursing home, they are at risk for serious harm due to the physical and mental deficits they have related to their underlying infirmities. They are at risk of injuries due to falls, being struck by a car, becoming a victim of a criminal assault, or as here, falling in a river and drowning.
One of the basic assessments as part of the care planning process when a resident is admitted to a nursing home is an elopement assessment. If a resident is identified as being at risk for wandering from the nursing home, this is something that must be addressed in the resident care plan which must then be carried out day-to-day, shift-to-shift. When there is an inadequate care plan or one which is not carried out on a regular basis, then a resident is placed at risk of all of the calamities that can follow.
There are a number of standardized risk assessment tools, but in the end, the resident who is at high risk of wandering from the nursing home has the following characteristics: 1) some form advanced dementia, where they cannot be counted on to follow instructions or make good decisions for their own safety, usually with some degree of disorientation, 2) an ability to ambulate reasonably well, as residents who have limited mobility or who are bedbound are not able to leave the nursing home effectively, and 3) some demonstrated intent to leave, whether by actually trying to exit the facility or an expression of an intention to leave (“I want to go home, to my daughter’s etc.”).
The usual approach to caring for a resident such as typically a mix of interventions, but the most crucial ones would include placing an alarm on the resident which sounds when they try to leave the building or the unit they resident on, close supervision, and other interventions intended to reduce the resident’s overall level of anxiety or agitation.
The resident at issue suffered significant issues with dementia for a host of reasons. He had demonstrated a host of behaviors which showed that he was an elopement risk, including actually trying to leave the facility and expressing an intention to leave. He was care planned for elopement which included the use of an electronic wandering device, identifying a pattern of wandering, and intervening as appropriate. There was no specific requirement for supervision or monitoring of his activities and no care plan to address wandering and exit-seeking behaviors.
On the morning that the resident left the facility, he was caught by a staff member at 9:30 a.m. getting onto an elevator to go downstairs. Approximately an hour and a half later, he could not be found during the medication pass, so the staff called a Code Pink (for missing resident),but he could not be found in the building or on the surrounding streets. A police report was made, but sadly, he was not found until his body was pulled out of the river.
The staff member who last saw him before he left the building told the state surveyor that his wandering alert bracelet was on when he was last seen, and indeed, it was still on the body when it was recovered from the river. The state investigation was not able to establish exactly how the resident got out of the building, but there are a limited number of options, none of which reflect well on the nursing home. Since the bracelet was on, either it or the alarm by the elevators was not working, or the staff failed to respond to the alarm when it sounded. No matter how this happened, there was an egregious breakdown in the systems that are intended to keep the residents safe.
One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Order our FREE report, Built to Fail, to learn more about why. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.
Other blog posts of interest: