IDPH has cited and fined Bria of Alton after a resident wandered from the facility and suffered a fractured knee.
The resident in question had diagnosed schizophrenia, hallucinations, and a prior elopement incident. In addition, his previous facility assessments clearly deemed that he was incapable of safe outdoor access alone.
The resident recounted to investigators that on the evening of the incident he exited the front doors of the facility between 11PM-12AM as two other individuals were also leaving. The resident did not think these people were staff members and told them that he was simply “leaving too.” He subsequently signed himself out, but did not list a return time on the checkout form.
The resident wandered a bit less than a mile from the facility and subsequently decided that he wanted to sit under a nearby tree. As he lowered himself down, the resident reported that he heard a “pop” in his right knee and felt pain.
Despite occasional rain the resident remained under the tree throughout the night and into the next morning.
It was not until lunchtime that staff noticed the resident was missing. At this point a nurse took her own car and began to search the neighborhood for the missing resident.
When she found him sitting under a tree he was reported to be confused, giving a different name for himself and talking about raccoons. He complained of knee pain and inability to stand.
911 was called and the resident was taken to the hospital for evaluation where x-rays showed a fractured right knee – the tibial plateau.
He subsequently returned to the facility that evening where staff monitored him closely to prevent another unauthorized exit.
Several issues emerge in how the facility handled the resident’s situation:
1. Failure to Adequately Assess Wandering Risk
Despite clear prior incidents and assessments showing the resident’s tendency to wander/exit without supervision, the facility did not classify him as an elopement risk or take proactive measures to prevent an unauthorized departure.
2. Inadequate Supervision and Tracking of At-Risk Residents
On the night of the incident, nursing staff were unaware the resident had exited the building and could not confirm visibly seeing him at any point through the overnight hours until he went missing the next day. No effective system was in place to monitor when he signed out or verify his physical whereabouts.
3. Delayed Reaction to Missing Resident
The fact that the resident had signed himself out on leave of abscence forms was initially given more priority than the fact he had completely disappeared without anyone noticing for almost 24 hours. The Administrator did not view this as a true elopement situation. The reaction time shows insufficient vigilance and protocols for missing residents.
4. Outdated or Ineffective Elopement Prevention Policies
Though the facility’s elopement policy mandates close monitoring of at-risk residents, this was not implemented in this case. The policy lacks specifics on what qualifies as an elopement event and how to respond if residents cannot be located. It needs updated guidance reflecting the facility’s layout, exit areas, and resident population.
In summary, multiple gaps emerged in how staff evaluated the resident’s exit risk, supervised and tracked his movements, responded urgently when unable to locate him, and applied policies meant to prevent unsafe wandering. Updating systems, training staff, and clarifying protocols could help address these shortcomings highlighted by this resident’s experience.
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