State investigation of wandering death
This entry is a follow-up to the entry about a resident in Concord, N.C. who was allowed to wander away from the nursing home and fll off a loading dock. A state investigation shows that a nursing home in Concord made several mistakes, which played a role in the death of a patient. The 21-page report says that the staff and director of Five Oaks Manor knew that 87-year-old Annie Bell Scarboro was at risk for wandering because she had wandered off before.
State inspectors from the Department of Health and Human Services went into Five Oaks Manor in December after the Alzheimer's patient died. The report shows Scarboro got through three sets of doors unsupervised.
First, she went through the dining room doors. A worker says those doors hadn't locked properly for at least eight months. Then, Scarboro went through the kitchen doors and out a back door leading to the loading dock. The back door, according to the report, had no alarm.
Scarboro fell 4 feet off the loading dock .The "merry walker" chair she used to get around landed on top of her. A nurse who found Scarboro told inspectors, "I went out there and saw her blood was running everywhere."
A nursing assistant at Five Oaks told investigators, "Everyone knew that she wandered around. We all knew that she did that. She got out that kitchen door before." The report shows that on May 22, 2008, Scarboro had exited the building through the same kitchen door. The solution then was to check on her every 15 minutes.
The state investigation found the nursing home failed to meet several federal standards of care, meaning Five Oaks could be forced to pay a big fine and could lose their funding altogether.
NewsChannel 36 tried to get comment from the director, but he hung up on us.
To view the full 21-page report, click here. The report does not mention the staffing levels at the time of the incident.
