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Unsupervised Nursing Home Resident Wandered Off Property of Hilltop Manor Health Care Center

Elder neglect

Michigan Nursing Home Inspection Report

The Michigan Department of Licensing and Regulatory Affairs (LARA) conducts yearly inspections of nursing homes and long-term care facilities to ensure they are compliant with state and federal regulations.

Nursing home violations are documented in detail.  Reports must be posted by the facility and made available to residents and family members.  Serious violations are ones that put residents in immediate jeopardy.  Inspectors who cite immediate jeopardy (IJ) violations will stay on site until the situation is resolved.

Hilltop Manor Health Care Center

Roscommon, Michigan

An 89 year-old resident at Hilltop Manor Health Care Center was found to be in immediate jeopardy after he wander off, unnoticed by staff, from an unsecured outdoor courtyard area attached to the facility.  The gentleman suffers from dementia and has a history of seeking out exit doors and trying to leave.  Fortunately, he was not harmed in the incident.

A nursing assistant was assigned to stay outside with the residents at all times while they were in the courtyard.  Instead, she went inside of the building, leaving the residents completely unsupervised.  While the nursing assistant was in the building, the resident exited the courtyard through an unalarmed gate.  He made his way from the back of the building to an apartment complex across the street.  A nurse, who was in her car leaving work, noticed the resident wandering around the complex parking lot.  He was gone from the facility for approximately ten minutes before the nurse saw him.

In an interview with the Director of Nursing, the nursing assistant acknowledged that leaving residents alone outside was not proper procedure, but never answered why she did so.  The nursing assistant was fired for her negligent behavior.

Permanent alarms were installed on the courtyard gates.  New guidelines were written on proper procedures for courtyard use, and staff was retrained.  With these new measures in place, the immediate jeopardy was removed.