A wrongful death lawsuit has been filed against a former New York nursing home for the death of a resident in its dementia unit who fell 34 feet while using a makeshift rope to climb out his window. The lawsuit alleges that negligent, careless, and reckless care of the resident at the nursing home led to his death.
The health department investigation of the resident’s death found the following:
- On ten different occasions, maintenance personnel had replaced bolts that were placed on the resident’s window to prevent his window from opening more than 6 inches. The director of maintenance had warned the administration and nursing staff leaders about the removal of the bolts, and that they were unable to determine how the resident was removing the hardware.
- The resident had been homeless prior to hospital admission and was discharged to the nursing home in April 2018. He was also diagnosed as lacking decision-making capacity. Upon admission to the nursing home, the admitting nurse assessed that he was at risk for escape, but no elopement bracelet was placed on the resident.
- The care plan for the resident did not include interventions for preventing elopement or interventions requiring staff to know his whereabouts.
- A social worker’s report described the resident as being difficult and refusing all hands-on-care and medications. The report also stated that the resident frequently said, “I’m going out of here.”
- Some of the nursing staff told the state inspectors that they were unaware that the resident had previously removed window bolts.
The lawsuit also states that the facility’s psychiatric nurse practitioner had not been notified of the repeated removal of the bolts. The nurse practitioner stated she would have expected to have that information given to her, and if it had been, she would have recommended that the resident be checked every 15 minutes.
The nursing home was fined $10,000 by the Department of Health in the resident’s death for failing to properly protect the resident. In 2016 the nursing home was also fined $10,000 in the beating of a resident who suffered from dementia, after she mistakenly wandered into the room of another resident on the dementia unit.
The nursing home was designated as a special focus facility by federal monitors after the resident’s death and identification of other repeated safety concerns. It closed in January 2019, after the Department of Health appointed a receive to operator the facility.
The lawsuit lists the defendants as the companies that owned the nursing home, the real estate company, and a passive investor of the nursing home. The lawsuit claims that the defendants are individually liable for negligent management and negligent financial decisions that resulted in negligent, careless, and reckless care, including but not limited to, failing to provide sufficient staff, failing to properly train staff, and otherwise providing insufficient resources necessary to provide proper services and care to residents.
Compliance Perspective
Issue
Every resident upon admission and at least quarterly should be assessed for elopement risk. Residents that have been accessed as high risk for elopement should have a care plan in place that lists interventions to keep the resident safe and free from elopement. The medical team should always be made aware of any elopement attempts, and the care plan should be updated as necessary. Safety should be the priority for all residents. Failure to keep residents safe from elopement may be considered immediate jeopardy, provision of substandard quality of care, and a violation of state and federal regulations.
Discussion Points
- Review your policies and procedures for assessment for elopement risk and prevention of elopement, and determine if improvements are needed.
- Train all staff on appropriate interventions for residents that have been assessed as high risk for elopement. Document that the trainings occurred, and file the signed training document in each employee’s education file. Conduct elopement drills to determine the level of staff competency in responding to a missing resident event, and provide additional education as needed.
- Periodically audit to ensure all residents deemed to be at-risk of elopement have an appropriate care plan in place, and that staff are following the individualized care plan interventions for each of these residents.
FOR MORE INFORMATION ON THIS TOPIC view: ELOPEMENT RISK AND PREVENTION MEASURES.
