An 89-year-old resident who wandered away from a Connecticut nursing home in January was found deceased just fifty feet outside of the facility. His cause of death was determined by the medical examiner to be from hypothermia, although he had only been exposed to the mid-30s cold weather for just over an hour.
Hypothermia occurs when the body becomes cold and loses heat faster than it can recover. In addition to the hypothermia, the medical examiner found “Complicating Alzheimer’s Dementia” and contributing conditions of hypertensive and atherosclerotic cardiovascular disease.
The death was ruled an accident.
When the resident was found, he was wearing just a shirt and one sock, and had bloody knees and muddy feet. The Connecticut Investigative I-Team (CHIT) revealed that staff had failed to perform required two-hour check-ins of the residents. Also, CHIT reported that instead of having the required four aides on duty for the 11 p.m. to 7 a.m. shift, there were only three aides.
Compliance Perspective
Issue
Failure to ensure that staff perform assigned checks of residents, and failure to meet staffing requirements, may be deemed a breach of residents’ rights to a safe and secure facility that is free from neglect. Additionally, it could be considered non-compliance with requirements for sufficient numbers of competent staff. These failures may place residents in immediate jeopardy for elopement due to inadequate monitoring, and could be considered provision of substandard quality of care, in violation of state and federal regulations.
Discussion Points
- Review policies and procedures for ensuring provision of adequate monitoring, sufficient staffing, and that there is adequate security to prevent residents from wandering away from the facility.
- Train staff regarding abuse and neglect and the importance of providing adequate monitoring and care for the residents.
- Periodically audit to ensure that staffing levels meet state and federal requirements, and that staff are performing assigned checks of residents.
FOR MORE INFORMATION ON THIS TOPIC view: ELOPEMENT RISK AND PREVENTION MEASURES
