Connecticut Department of Public Health Recently Cited and Fined A Nursing Home for Multiple Violations Including Three Elopement Incidents
A Connecticut nursing home was recently fined $6,300 for multiple violations that included separate incidents involving the elopement of three different residents.
One of the elopements involved a resident diagnosed with schizophrenia who was able to leave the facility without any staff member noticing. According to the citation, a surveillance camera was able to capture on video the resident leaving the facility by following behind emergency medical service workers as they left. The resident proceeded to take a city bus to a family member’s home in a nearby town. The family member returned the resident promptly to the facility.
In another instance, the police found a resident who had wandered away and notified the facility at 9:46 p.m. However, the resident refused to be returned to the facility so was sent to an emergency department for evaluation. Again, surveillance video showed the resident walking outside the facility at 8:05 p.m. An investigation determined that the resident was able to leave through a secured stairwell door when a staff member exited.
Another elopement involved a resident who called 911 complaining of chest pain, and EMTs came and took the resident to a hospital’s emergency room. However, soon after that, the resident was observed walking down the street near the facility. He was confronted and admitted that he had gone to a bar and consumed some alcohol, so he was taken to another hospital to be evaluated where he tested positive for cocaine. The resident was returned to the facility and was placed on 15-minute checks, but staff failed to perform the checks as required. A few days later, the resident again left the facility without being seen through a door that was supposed to be secure; however, a staff member had left it propped open while he was repairing it.
Compliance Perspective
Failure to prevent residents from venturing outside the facility unnoticed through exit doors that are intended to be secure may place residents in immediate jeopardy for harm and could be deemed provision of substandard quality of care, in violation of state and federal regulations.
Discussion Points:
- Review policies and procedures for maintaining doors/exits to ensure they are secure and capable of preventing residents at risk for elopement from leaving the facility and becoming injured or lost.
- Train staff to maintain current and comprehensive risk assessments for residents with a high risk for elopement. Provide training on protocols for redirecting residents who may be trying to leave the facility. Training should be provided to maintenance personnel to not leave a “secure” door ajar and unattended even though repairs are being made to the door.
- Periodically audit the elopement risk assessments of residents to ensure they remain accurate. Audit to ensure that secure doors are monitored to prevent residents from leaving by following other persons when they exit the facility.
