New York Nursing Home Fined $20,580 After Wheelchair-Bound
Resident Elopes Unnoticed
Federal authorities recently fined a New York nursing home $20,580 after a cognitively impaired wheelchair-bound woman with a history of wandering eloped unnoticed from the facility.
Based on the New York State Department of Health (NYSDOH) inspection report, prior to the elopement, maintenance staff were aware that the alarm on the stairway door of the resident’s unit was malfunctioning; however, nursing staff were not notified about the malfunctioning alarm.
A video that was reviewed by state investigators showed the resident pushing her wheelchair through that second-floor stairwell door at 6:02 a.m. on the day of her elopement. The resident was not discovered as missing for more than one and one-half hours. The confused but uninjured resident was found sitting on the floor at the foot of the stairwell.
A certified nursing assistant (CNA) falsely stated in a written report that she had checked on the resident at 6:40 a.m., and she was in her bed—something that the video showed was untrue.
The NYSDOH cited the facility for its failure to thoroughly investigate an alleged violation and determine why the resident was able to wander away from her unit unnoticed. Additionally, the facility was cited for failing to provide adequate supervision of residents to prevent accidents.
The door was repaired, and the resident was relocated to a more secure memory care facility operated by the company owning the nursing home.
Compliance Perspective
Failure by maintenance personnel to notify nursing staff that an alarm on an exit door was not working, failure to provide adequate supervision of residents at risk for wandering, not conducting a thorough investigation of an alleged violation, and allowing a false statement to be given by a staff member may be considered immediate jeopardy and provision of substandard quality of care, in violation of state and federal regulations, resulting in fines and other sanctions.
Discussion Points:
- Review policies and procedures regarding maintenance of the facility’s alarm system, incident investment protocols, and ensuring that adequate supervision is provided for residents at risk of wandering.
- Train staff about each departments’ responsibility to regularly inspect, report, and repair malfunctioning alarms or other system failures; provide adequate supervision to residents at risk for elopement; the importance of completing a thorough investigation of any alleged incident; and reviewing videos to validate statements of staff to prevent false reporting.
- Periodically audit alleged reports to determine if investigations are being thoroughly conducted. Review maintenance reports to ensure that system malfunctions are being reported to nursing staff and promptly repaired.
