Nursing Home Cited After Resident Elopes Three Times from Facility

The Retreat at Brightwater in Myrtle Beach, SC was cited after the facility “failed to review and revise [a resident’s] care plan for elopement.” The resident – who was deemed the “highest risk” for elopement – wandered outside of the facility two times before the facility updated the care plan to keep the resident safely inside.

The investigator of this citation reviewed documents regarding the resident’s past elopement behavior. The records revealed the resident was “wandering in rooms and hallways and calling for his/her son/daughter. Acts of diversion and reorientation were used as requested by the son/daughter.” According to the citation, “no new wandering/elopement risk screening was performed, and no new interventions were added to the resident’s care plan.”

Further review of a nurse’s notes showed that the resident was found one night, wandering outside around midnight. The resident was confused about where they were. The resident left the facility again a few days later without anyone noticing. This time, the resident was found down the road and across the street. The nursing home’s courtesy officer used a golf cart to retrieve the resident. Even after these two instances, the resident’s care plan was not updated. There were no new interventions put in place to keep the resident safely inside the facility.

During an interview with the Director of Nursing (DON) and facility administrator, the DON confirmed nothing was done to keep the resident from leaving the facility. The DON also reviewed the resident’s care plan to see if they had a “wanderguard device.” Wandergaurd devices are used to support caregivers by triggering alarms or locking monitored doors from afar to keep residents from leaving. A device like this was not given to the resident until they had already left the facility two times.

Upon further investigation, the investigator discovered that the resident managed to leave the facility a third time, even with a wanderguard device. They were found right outside the gates on the sidewalk. After the resident was brought back to the facility, there was “no documentation that a new wandering/elopement assessment was performed and there were no new care plan interventions.”

During an interview, a CNA (Certified Nursing Assistant) was asked when she was last trained on elopement/wandering. She stated, “I don’t remember the exact date. It was a couple of weeks ago.” The investigator then asked why the CNA’s signature was on the sign-sheet attached to training information. The CNA said, “because they told me to.” She had not received any training before signing the form. The CNA stated she “usually does training from home but had not done any in a while.”

The facility in this citation didn’t follow through on several critical processes to keep a resident safe. Because of this, the resident wandered about the facility, ultimately leaving the nursing home. This put the resident at risk of getting lost completely or even getting hit by a car in traffic. In addition, even though the facility knew the resident was a high risk for eloping, they did not take the necessary steps toward updating and implementing a care plan. They also instructed a CNA to say she had completed a training on elopement behavior by signing a paper, when she really had not. These kinds of actions not only put the resident in this citation in danger, but all residents who are a high risk for eloping.

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