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State Steps In After Second Episode Involving Patient Elopmement At Same Facility

Screen-shot-2010-07-20-at-1_07_07-PMI think its downright scary when facilities fail to learn from their mistakes.  Of course, — any person, — any facility can make a mistake one time, but when the same errors are repeatedly made I feel there is well deserved cause for concern.

An episode of a patient wandering from Brentwood Assisted Living facility, would normally not be a particularly noteworthy event— especially since the eloping woman will hopefully recover from her injuries.  What deservedly brings more attention to this incident is the fact that this was the second patient to wander from this facility this year!

In the most recent occurrence, the Michigan Department of Human Services is investigating the incident in which a 91-year-old woman wandered from the assisted living facility with her walker.  Three days later, the woman was discovered by neighbors in the area at the bottom of a heavily wooded ravine.

As DHS investigates this incident, just months before the agency investigated a similar incident in which a patients eloped from the facility.  After the agencies investigation, it was revealed that Brentwood: 1) failed to monitor the patient in accordance with their care plan that identified them as being at high risk for eloping and 2) failed to timely notify the patients family of the occurrence.

Patterns of poor care

Of course, episodes of poor care should give rise to concern.  However patterns of poor care really should give rise to alarm both on the part of families who have loved ones at this facility and on the part of the state.

Even though it appears that neither patient involved in these elopement events was injured seriously, I hope that the state recognizes the severity of these lapses in patient care and reprimands the facility accordingly.

Episodes involving patient elopement and wandering rarely end as well as it did for these patients.  Unfortunately, when patients wander from a nursing home or assisted living facility they are ill-equipped to deal with the world around them.  In our nursing home abuse practice, we have worked on several cases where patients received severe injuries or were killed after they left the safe confines of their facility.


Assisted living and nursing home patients with dementia and Alzheimer’s are commonly known to elope from their facilities. On admission, the facility should conduct an assessment of the patient (with family if possible) and determine the persons risk level for eloping from the facility.

Once an assessment has been completed, the implementation of simple preventative measures implemented by a facility to assure the patient remains safely at the facility.  Assisted living facilities and nursing homes that care for patients who are at risk for eloping should have the following safeguards in place:

  • Door alarms
  • Window locks
  • Door locks
  • Bracelets that track each resident’s location
  • Hire adequate staff to look after residents
  • Have contingent plan to locate patients in the event a resident elopes from the facility

Related Nursing Homes Abuse Blog Entries

Assisted Living Facilities Need To Re-Evaluate If They Are Capable Of Caring For Dementia Patients

Chicago Nursing Home Lawyer, Jonathan Rosenfeld, Interviewed Regarding Preventing Patients From Wandering From Their Facilities

Three Employees At Assisted Living Facility Disciplined For Their Failure To Report Missing Nursing Home Resident

What Can Nursing Homes Learn From Jails?

Nursing Home Negligence Lawsuit Filed After Man Wandered From West Virginia Facility

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  • Of course, you also have to assume that nursing homes are interested in learning from their mistakes. I don’t always think that is true. I have heard too many administrators and DON’s talk about plans of correction after prior citations as being just something that they had to do to resolve the citation, and could not describe how they went about actually implementing the plan of correction. Not being interested in getting things done right is how you end up with the same mistakes happening again and again.

  • Barry-
    Point well taken. Is it just a coincidence that we continue to see the same facilities getting sued over and over again. Of course not!
    I believe change really starts from the top to the bottom. Until nursing home owners and management make patient care a priority and give the staff on the front-lines of patient care the proper tools (and staffing levels) to do their job properly, the cycle of poor care will continue.
    Hopefully, the more attention that gets heaped on poorly performing facilities will result in public demand for better care. Until this happens, I fear that many facilities that have a culture of poor care will endure.

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