Tuesday, January 6, 2009

Alden Heather Fails to Prevent Patient from Wandering

FINED- 2003
Alden Heather Rehab and Health Care Center was fined
$50,000 for failure to take necessary precautions to
prevent a resident from leaving the facility
unsupervised.
Responding to a complaint, Department surveyors
learned a resident, who had a history of wandering,
left the facility unnoticed and froze to death before
staff found her in an alley behind the nursing home.
When staff realized the resident was missing, the
building and grounds were searched and the resident
was found in the snow, wearing only a T-shirt, sweat
pants and slippers. Her body temperature was 84
degrees.
A review of the nurse's notes revealed that the
resident would wander during the night and had
previously attempted to leave the facility. Because of
this behavior, her whereabouts were to be monitored
every two hours. However, there was no evidence that
this was done.
During the Department's investigation, surveyors
observed that the facility's front doors did not have
an alarm. The administrator told surveyors that the
doors were monitored between 8 a.m. and 8 p.m. There
was no supervision of the doors during the time the
resident left the facility.
The Department-ordered plan of correction required
the facility to provide residents with adequate
supervision and to ensure all resident-accessible exit
doors are equipped with functional alarms or are
constantly monitored.

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