The children of a 73-year-old resident in an Ohio nursing home recently filed a complaint with the Ohio Health Department (OHD) over their concern about their mother’s safety and care. The resident’s children took her out of the facility for an outing to Starbucks, and when they returned her at 4:30 that afternoon, the son was not allowed inside to escort her to the correct floor as he was normally allowed to do. The resident needed assistance due to her dementia. Staff assured the son that a nurse would meet her at the elevator.
The family was upset that the facility did not make them aware that she was missing until 1:30 a.m. the next morning after she had been missing almost 9 hours, and just before she was found.
The facility issued this statement about how the incident occurred:
“This resident returned to our community from a family outing, was guided to an elevator, and subsequently got off the elevator onto the wrong floor. The floor the resident exited onto was a new, fully renovated, and vacant floor that had not yet opened for use, so there were no staff present on the floor. The resident remained on this floor for several hours and was discovered early in the morning unharmed. We feel terrible that our resident went through this experience. The safety of our residents is our top priority, and we deeply regret and are very sorry that this happened. We immediately launched an investigation into the incident, and we have implemented enhanced protocols in an effort to ensure the safety of our residents. We are grateful that the resident was found unharmed and hope that by putting into place enhanced safety protocols, an incident like this will never happen again.”
The OHD officials would not comment on the complaint due to it being an ongoing investigation.
The family removed the resident from the facility, and she currently lives with her children.
Compliance Perspective
Failure to ensure that residents with dementia returning from outings are properly checked-in and escorted to their rooms may result in residents being placed in immediate jeopardy due to their ability to wander internally or to exit the facility unsupervised, with potential for endangerment or harm. This breaches residents’ rights to safety and violates state and federal regulations.
Discussion Points:
- Review policies and procedures regarding protocols to be followed when residents go on outings with family and are later checked back into the facility, with a focus on situations where family members are not permitted to enter the facility and the resident is diagnosed with dementia or needs other assistance. Ensure that policies and procedures address provision of aid in locating their rooms for residents with dementia and other conditions.
- Train staff to be aware of residents who have returned from family outings to ensure that they are assisted to their rooms and not left to wander unsupervised.
- Periodically audit to determine if protocols for checking residents in and out of the facility for outings are being followed, and that staff are monitoring residents to prevent them from wandering and being placed in serious jeopardy.
