History Of Errors Discovered At Illinois Nursing Home Where Patient Wandered To His Death

IDeath As Result Of Nursing Home Errorst seems like the staff at Midwest Rehabilitation & Respiratory Care in Belleville, IL needs a refresher course in caring for patients with a propensity to wander. Last month the facility made headlines when a 77-year-old dementia patient wandered a short distance from the facility and died due to exposure to the elements.

Now, following an investigation by officials from the State of Illinois Department of Health, it appears that the man had prior episodes of attempting to leave the facility– yet the facility failed to take the necessary steps to prevent the situation from occurring again.

A recent article in the Belleville News-Democrat by Kevin Bersett, “State: Belleville nursing home negligent” discussed the utter lack of safeguards in place at the facility intended to protect patients such as this man. When interviewed by state officials, nursing home employees conceded that they never heard any door or window alarm (to alert them that a patient had left the facility) on the day of the man’s disappearance. Further, staff was aware that the man should be wearing a monitoring device—yet staff allowed the man to remove the device.

All told, the state officials dispensed eight citations to Midwest Rehab concerning negligent care in the manner the facility handled both the care of the patient who recently wandered from the facility as well as for other issues identified during the inspection.

Officials were so concerned about the lack of wandering safeguards they issued considered the situation to pose an ‘immediate jeporardy’ to the patients at the facility and ordered the following corrective measures be implemented on the spot:

The surveyor confirmed through interview, record review and observation that the Facility took the following actions required attention to remove the Immediacy:

1. On 1/15/12, the facility conducted individual in-service training for all staff. All staff were in-services on the following policies and protocol: Elopements, Wandering Residents, Missing Residents, Head Checks and Drills, Elopement Drills, Door Alarms, Behavior Tracking, Tracking Sheets, Residents Currently on Tracking and/or (patient monitoring device) and the (patient monitoring device) System Policy.

2. On 1/16/12, the facility reassessed all current residents in the facility to determine wandering risk status. Following this, all high risk residents care plans were reviewed and changes made as necessary.

3. On 1/16/12, a Quality Assurance (QA) Meeting was held and all areas of the facility were reviewed to determine the possible exit route of the missing resident and other possible problem areas that exist. New preventative measures were implemented at that time as needed.

4. On 1/16/12, the QA committee reviewed all related policies and revisions were made as needed.

5. On 1/16/12 and on-going, secondary keyed door alarms were installed on all exit doors accessible to residents.

6. On 1/16/12, all high risk resident’s information was placed in a binder at each nursing station and at the front desk. Each binder included the individual residents face sheet, a current picture, room number and specific interventions to be in place.

7. On 1/16/12, Receptionist’s hours have been extended and are now from 8:00 AM until 9:00 PM to provide additional monitoring of our main entrance.

8. On 1/16/12 and on-going, all door alarms will be checked by Maintenance daily (Monday-Friday) and by the weekend manager on Saturday and Sunday to ensure they are in proper working order. These checks will be documented at the time they are completed. Batteries will be changed monthly and as needed.

9. On 1/16/12 and on-going, Elopement Drills will be conducted monthly, alternating shifts, and randomly per Director of Nurse’s (DON) and/or designee. 10. On 1/16/12 and on-going, Head Check Drills will be conducted monthly, alternating shifts, and randomly per DON and/or designee.

11. On 1/16/12 and on-going, an initial Wandering Assessment will be completed on all new admits on the day of admission, in conjunction with their 14 day assessment, quarterly and PRN. Follow-up will be implemented based on the results of the assessment.

12. On 1/16/12 and on-going, patient monitoring devices will be checked daily by the MDS nurses Monday thru Friday and on the weekend by the weekend manager.

While the above safety measures seem justified, I find it sad that give the inherently basic nature of most measures, these were not implemented without an intervention from officials. In light of this publicized nursing home error and the prospect of facing a civil lawsuit from the deceased man’s family, I hope that this provides enough incentive for management to begin changing the way they operate and start giving patient needs a priority.

Related Nursing Home Law Center LLC Blog entries:

Illinois Officials Begin Examination of Nursing Home Procedures Following Elopement Of Alzheimer’s Patient

Investigation Initiated After Suspicious Nursing Home Death, Involving Patient Wandering and Drowning

Too Little, Too Late. Nursing Home Submits Corrective Plan After Disabled Patient Wanders From Facility To His Death

State Fines Nursing Home Where Patients Drowns In Puddle In Front Of Facility

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