IDPH has cited and fined Mercer Manor Rehabilitation when the facility failed to follow their elopement policies and failed to provide adequate supervision of a resident that eloped from the facility. As a result, the resident that eloped suffered a severe fall in the parking lot and was later transferred to the hospital where he was admitted to an intensive care unit for treatment of facial and cervical spine fractures.
Elopement is the technical term for wandering from the nursing home and is something that poses a serious risk to residents who do so. One of the basic factors driving a family’s decision to admit a family member to a nursing home is the fact that they are unable to keep a loved one safe at home. Sometimes that is due to the fact that they wander from home due to advancing dementia and confusion and are unable to make good decisions about how to keep themselves safe.
When a nursing home accepts a resident into their facility, there are a number of standard assessments which are done as part of the care planning process. One of these is assessment of elopement risk. Every facility has a slightly different tool for assessing risk of elopement, but there are three main risk factors that show that a resident is at risk for elopement: (1) confusion, a mental health disorder or dementia, (2) the ability to ambulate (someone is not a high risk for leaving the facility if they cannot get around reasonably well), and (3) either an expressed desire to leave (“I want to go home”) or a history of having left the facility or having attempted to do so.
If a resident is at risk for elopement, then a care plan must be put into place which is tailored to the needs and behaviors of the particular resident. Frequently, this involves placing them in a locked unit so that they cannot easily leave the facility. Past that, it also usually includes regular, close supervision of the resident and either monitoring and/or alarming of exit doors and windows.
The resident in question, with diagnoses including unspecified dementia, psychotic disturbance, and mood disorder, managed to exit the facility unnoticed through a door at the end of a hall.
At approximately 5:45 PM, during heavy rainfall, the resident was discovered by a nurse arriving for her shift. The resident was found “soaking wet, laying on the parking lot pavement with facial and head trauma accompanied with excessive bleeding, approximately 50 to 70 feet from the exit doors.” The resident was partially sitting, attempting to push himself up when staff reached him.
Emergency services were called, and the resident was transferred to the local emergency room. Due to the severity of his injuries, the resident was subsequently transferred to a tertiary hospital that same night and admitted to the intensive care unit. The extent of the resident’s injuries was significant, including fractures of the thoracic spine, cervical spine, bilateral mandibular (lower jaw), and a closed maxillary (upper jaw) fracture.
The incident revealed multiple failures in the facility’s elopement prevention and management procedures. Despite the resident being assessed as high risk for elopement and having a history of exit-seeking behavior, the facility failed to implement adequate supervision and prevention measures.
The facility’s alarm systems also proved ineffective, with staff reporting that alarms were often inaudible in certain areas of the unit.
Furthermore, it came to light that the resident had experienced a previous elopement incident which was not properly reported, investigated, or used to update his care plan.
This failure to address the earlier incident likely contributed to this more serious elopement event.
In summary, this incident exposed a series of critical failures by the care facility in safeguarding its vulnerable residents with cognitive impairments. This case underscores the vital importance of rigorous elopement prevention protocols, effective communication, and strict adherence to safety policies in residential care facilities serving individuals with dementia.
One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.