Resident Dies After Getting Locked Out of Nursing Home Facility

Linville Court at the Cascades Verdae in Greenville, SC, was cited after the facility “failed to provide adequate supervision for a resident in a weakened physical state from multiple medical conditions.” The resident exited the facility at 3:05 AM and could not get back inside the building because the doors auto-lock. He was found two hours later, where he was ultimately pronounced dead.

The investigators reviewed the facility’s security video footage to track the resident’s movements the morning of the incident. The citation lists in details the events that occurred in the footage:

The resident opened the exit door and walked out. No staff were seen in the area on the video. [The resident] was fully dressed and his nasal canula was in place, but the oxygen tubing was draped behind him and not connected to the oxygen tank. The resident was wearing his shoes and had his glasses on. The resident stood outside on the sidewalk by the door for about 5 seconds with his back to the door. When he turned around to face the door leading back inside the building, he was slightly off balance and leaning to one side. [The resident] tried to open the door to re-enter the building, but the door would not open. The resident was not observed to knock on the door or call out for assist. The resident stood there looking in the door for a time. There were no staff noted to be in view during the piece of the security footage of the incident shown to the surveyors. The video ended with the resident just standing facing the door.

The facility shared this short piece of footage but no other footage. The investigators requested a full copy of the footage, but it was not provided. There was no video evidence of the resident walking around the building to get to the front doors. However, the Administrator stated “the resident walked away from the door he exited, toward the parking lot after he was unable to get back in the building…. He must have walked off the sidewalk because he was found by staff lying face down on the grass about 60 feet from the sidewalk by the window of [a] room.” The Administrator also stated the resident was unresponsive, even after attempting CPR.

The investigators reviewed the facility’s Move-In Packet, which confirmed that there was no information given to any resident that the exit doors lock automatically when you leave the building. The Administrator confirmed there were no alarms on the exit doors to alert staff of residents who leave the building. There’s also no doorbell to alert staff that a resident needs to get back in.

Further review during the investigation revealed a note by a staff member who was present during the incident. The note said that a Private Sitter (PS) was on duty providing one-on-one care for another resident. The PS was asked to help check for the missing resident in this citation. The PS looked in the resident’s room and the TV room but was unable to find him. At this time, another staff member said she “had seen a body out of the window of a room.” The PS and the staff member went outside and found the resident face down on the ground. They turned him over, and he was wet like it had been raining; it was not raining at the time, but it had rained earlier. The PS and staff member noted the resident was not moving or speaking. He still had his glasses on.

The investigators reviewed the facility’s notes on the resident. The partially completed documentation revealed the resident had no mood or behavior issues and did not show signs of elopement. The resident could walk around but only with assistance from one staff member. He wasn’t steady when he walked, but could stabilize himself with the help of a CNA or walker. The resident’s care plan didn’t find the resident at risk for falls, but it did indicate he had a respiratory infection. According to another staff member, the resident was “totally cognitively aware of his surroundings.”

In response to the citation, the facility placed warning signs by the exit doors. The signs indicated that those seeking to the leave the facility would not be able to get back in without a fob (digital device that acts as a key). The facility also ordered ten doorbells that would send signals to staff members if a resident were to leave. The admission packet was also updated to include information regarding the exit doors and their auto-lock feature.

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