Houmatoday had an article about the tragic incident involving Etienne Adams, a 93-year-old nursing home resident.  His solo walk outdoors on a freezing night is the subject of a police investigation.  Luckily, the resident is in stable condition at Thibodaux Regional Medical Center after recovering from a fall outside Lafourche Home for the Aged and Infirm.  He is being treated for extended exposure to freezing temperatures. He was unconscious when police found him, and he has been unable to communicate since. Hypothermia had begun to set in.  His temperature dropped to around 83 degrees, while being exposed to outdoor temperatures in the high teens

Police investigators are trying to determine how Adams made it outside without any of the staff noticing and then stayed there without anyone noticing for hours. Officials are not certain how long he was outside of the home.

The nursing home has working security features available that include surveillance cameras, door alarms and a locked fence around the building.  Obviously either the security was not on or it was ignored by the staff.  There is also no video surveillance footage of Adams leaving his room. The nursing home’s cameras capture only what it is happening in real time but do not record.

Adams left the facility and fell off of a ramp outside the facility.  There is no record of nursing-home employees looking for Adams outside once they realized he was not in his room.  After being dispatched to the nursing home on a missing-persons complaint, police found Adams on the ground near the back of the property.  Officer David Melancon’s report said “it was apparent that he had been lying on the ground for several hours.

 Here is a follow up article from the DailyComet on the investigation. 
 

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NewJersey.com ran an editorial about the resident who was allowed to wander away from Preakness Healthcare Center in Wayne.  A resident with dementia wandered out of the nursing home and was found more than two hours later, roaming in the snow and ice and subfreezing weather. 68-year-old Vidal Mojica, was rescued by members of the Passaic County Sheriff’s Department. Mojica, who uses a walker to get around, was found behind the nursing home on Oldham Road wearing just a golf shirt, pants and shoes. Mojica was transported to St. Joseph’s Wayne Hospital, where he was being treated for exposure to the cold.

One Preakness employee said Mojica would have to have climbed unsupervised down three flights of stairs with his walker to leave the building. The employee also said Mojica is the second resident to wander away from the nursing home since it opened in October.

While we understand the need to protect the confidentiality of a patient, we are disturbed by the county’s stonewalling about the circumstances of his escape from the facility. This is an issue that concerns not just one Preakness resident and his family; it is an issue of deep concern to every county resident.

Numerous questions need to be answered:

How could a patient using a walker have escaped so easily? How could he have gotten so far so fast and remained unseen for more than two hours?

Is there some design flaw in the new building that makes it susceptible to such "escapes"? If so, what steps are being taken to correct them?

Finally, has this happened before, and how can we be assured it won’t happen again?

Such a lack of information about what appears to be a severe breach in security in a brand-new, $90 million facility that has already taken on the scorn of taxpayers is not something the county or facility administrators can afford to just slough off.

Perhaps there is a perfectly reasonable explanation of how a 68-year-old man using a walker was able to elude authorities for more than two hours. If so, we’d love to hear it.

The Buffalo News had a story about 3 nursing home employees who were only disciplined when the employees did not check on a resident or failed to report him missing for over 11 hours.  The Health Department found that the employees, over an 11-hour period, each noticed that Trent Lockridge was not in his room but did not report it.  The resident either fell, was pushed, or jumped from his second-floor room in Dosberg Manor on the night of Feb. 17, but his body was not found until the next morning.

The Health Department required that the facility discipline the employees involved, put in place new policies for ensuring the whereabouts of all residents and train its employees in the new system.

Health Department investigators visited Dosberg Manor after Lockridge’s death, interviewing staff members and reviewing facility records. Their report found that the first employee had responded to a Feb. 17 call from Lockridge’s roommate requesting help in closing the window. The employee noted that the window was wide open, Lockridge’s glasses were on the nightstand, and his walker was near the window. She neither investigated the fact that he was not in the room nor told anyone about it.  In fact, when first questioned by department investigators, she lied and told them that she had seen Lockridge in his room at 9:40 p.m. She later confessed to a co-worker that this was not the case, the report states.

The second employee, who went into the room at 11 p. m. as part of a daily census of residents, assumed that Lockridge had been hospitalized but did not follow up on this or attempt to confirm it.

The third employee, who was assigned to Lockridge’s floor, stopped by the room at midnight as part of her rounds and also noticed that Lockridge was not in his bed, according to the report. Further, Lockridge’s medical records reflected that staff had helped him take a dose of medicine at 6:30 a. m. Feb. 18, when he was still missing. He was not reported missing until 6:45 a. m., when a nurse said she couldn’t find him. His body had been outside for at least 11 hours in freezing temperatures.

The report concludes that the employees should have notified a supervisor when they saw that Lockridge was missing and that the window was open. It does not name them.  Neither the Weinberg Campus nor the Health Department would say what disciplinary action was taken. Weinberg has agreed to put in place a new system for keeping track of Dosberg Manor residents and to train employees in the new procedures.

 

CBS2Chicago had a tragic story of a nursing home resident found on train tracks near the facility.  There is no excuse for this kind of neglect and lack of supervision.  The nursing home has been sued for negligence after a resident with dementia was discovered lying on train tracks and suffering from cold exposure eight hours after wandering off during a group field trip. McCauley suffered from various psychological and physical conditions, severe dementia and Alzheimer’s disease and required full-time supervision by staff.

Wayne Marz, the guardian of Margaret McCauley, filed the suit in Cook County Circuit Court against Sunrise Senior Living Services, the Brighton Gardens Assisted Living of Orland Park and the home’s Activity Director Debra Ann Adler, following the Dec. 2, 2007 incident that left the woman with significant injuries.

McCauley wandered away unnoticed and was found approximately eight hours later just one mile away, lying on train tracks with visible injuries she had suffered from falling down and from being exposed to cold temperatures for an extended amount of time.

The suit alleges Adler and the nursing home failed to properly monitor McCauley; failed to assess her risk of wandering off; failed to provide an adequate number of staff for residents and failed to ensure her safety.  The center also failed to take proper steps to ensure McCauley’s safe return after discovering she was missing.

 

I doubt that the facility even knew he was missing.  Staten Island Live had a story about a resident who walked away from the facility on Friday but the facility failed to either recognize that he was missing or failed to contact the police or his family for 48 hours.  This is outrageous but not a surprise knowing how short staffed most facilities are these days.

The man, identified as Richard Constable, 66, walked off the grounds of the 200-bed facility sometime Friday but staffers didn’t call police until Sunday morning, when a therapist finally noticed his patient was missing a session.

"They felt they would get a better [police] response if they waited until Sunday," said Claudia Hutton, spokeswoman for the state Health Department that licensed the facility. "We were surprised by that. You call the police as soon as you realize a person is missing."  Hutton, of the Health Department, said Lakeside probably would be given a citation in the case, and called the response "inappropriate policy."  Probably?  Why not definitely?

Lakeside has drawn complaints from neighbors who say the residents there are publicly drunk, urinate on lawns and litter properties with trash and cigarette butts. But Anthony Caccamo, who lives across the street, said the patients aren’t the problem.

"It’s the staff; they’re just nasty, miserable people," said Caccamo, 35. "They don’t care."

 

The Daily Herald had a story about another woman found dead outside a nursing home.  Nursing homes have a duty to properly staff and supervise the residents especially when they know a resident is demented or confused and attempts to wander off the premises. 

The article mentions that authorities are investigating the death of an 89-year-old Itasca nursing home resident, found in her nightgown and bare feet outside in subfreezing temperatures.  Sarah Wentworth died last week at the Arbor of Itasca.

Police said they received a 911 call and rushed to the private facility at 5:43 a.m.  By that time, the resident was unresponsive but covered in blankets, lying on a gurney inside the facility.  Nursing home staff reported they tried to revive Wentworth after finding her in an outdoor courtyard. She was pronounced dead shortly later. She had dementia, but the nursing home never documented a history of wandering off.

The circumstances that led to her tragic preventable death have sparked at least three investigations. Itasca Police Chief Scott Heher said police uncovered conflicting information after interviewing the nine Arbor employees who were on duty. He said police were told Wentworth was sleeping in her bed during a 3 a.m. well-being check, but that she disappeared by 5 a.m. when staff looked in on her again. An employee reported hearing an alarm door sound, but Heher said it was not investigated beyond a cursory hallway check.

Police question whether the 3 a.m. check ever occurred. Furthermore, Wentworth was not dressed in the same clothing when police arrived as she was earlier that morning.   Her clothing could not be found.

"I think she wandered out there alone," Chief Heher said. "It’s an absolute tragedy. There are a number of mechanisms in place at the Arbor to ensure these things don’t happen. Obviously, there was a systems breakdown that night. We’re investigating to see if criminal charges apply."

Reports on more than a dozen other unrelated Arbor complaints are listed on the state’s Web site.  The facility has a one-star rating, much below average, based on prior complaints, staffing levels and the results of its three most recent inspections, according to the Federal Centers for Medicare & Medicaid Services.

 

MSNBC had an article about a resident who was unsupervised and was able to leave the facility unattended.  Authorities are investigating the death of the female resident.   Reports indicate that Dorotha Gifford apparently walked out of the Heartland of Woodridge home without any of the staff noticing.  Several hours passed before Gifford was discovered missing.  Employees searched the grounds and found her dead outside at about 2:30 p.m. Gifford was pronounced dead shortly after she was found.

Temperatures hovered only a few degrees from zero for  the day she was missing. The cause of death is mostly like exposure to the cold. 

The home is owned by HCR ManorCare.  They released a statement to the media refusing to accept responsibility.

The article does not mention if she was a known wanderer or if there were locks or alarms on the door.  It also doesn’t mention how long she was missing or if the facility was properly staffed that day.  I hope there is an investigation and we find out some of the answers to these questions.

Rome News Tribune has a story about a male resident found dead in the nursing home’s utility closet.  Typically, these closets are locked and only certain staff members have access.  No one knows how the resident got into the closet or how he died.  

The man had been missing from a Georgia nursing home for two weeks but was found dead Wednesday in a utility closet at the facility.  The body of Walter T. Heath was found in a closet near the dining area of the Tara at Thunderbolt Nursing and Rehabilitation Center.

Heath had been missing since 5 p.m. April 16. He admitted himself into the Thunderbolt facility in February.  After he disappeared, the facility’s staff and Heath’s family members grew concerned about him.   Heath’s wheechair was left near the dining area the day he disappeared, not far from the utility closet where his body was found Wednesday morning.

Hopefully, the autopsy and investigation will reveal what truly happened.

Family of man who disappeared sues Gooding nursing home.  The family of a man who allegedly wandered away from the Idaho nursing home five years ago has sued thecorporation that operates the facility.

In the lawsuit filed on behalf of Magic Valley Manor resident John Henry Davis allege the home and Northwest Bec-Corp didn’t supervise him or keep him safe and free from harm.

Wendell, who suffered from Alzheimer’s disease, disappeared in July 2002.

I saw this story in a Pittsburgh paper.  I can’t believe they gave probation to a nurse who lied, changed medical documents, and covered up the circumstances of neglect that caused the death of a nursing home resident. 

What kind of deterrent is this?

Kathleen Galati who was a nursing home supervisor was sentenced to only five years’ probation.
She pleaded guilty in March to perjury, false swearing, criminal conspiracy, and tampering with evidence in connection with the October 2001 death of Mabel Taylor, 88, at Ronald Reagan Atrium I Nursing and Rehabilitation Center.

Allegheny County Common Pleas Judge David R. Cashman also banned Galati from working in health care during her probation.  So in five years she can go back to covering up neglect in nursing homes!

Atrium head Martha Bell helped cover up the death of Taylor, who died after wandering outside on a cold night.  Bell was convicted of involuntary manslaughter and health care fraud and sentenced to at least seven years in prison.