On June 1, 2023, Greenfield Rehab and Nursing Center in Royal Oak, Michigan received a citation for failing to ensure that the nursing home area was free from accident hazards and failing to provide adequate supervision to prevent accidents.

The citation related to an incident where a resident who was previously identified as an elopement risk and had severe cognitive impairment, exited the building and left the facility premises without staff supervision, increasing the likelihood of serious injury, serious harm, serious impairment, or death. After realizing that the resident was not in his room, a code was called and a search was begun for the resident. It was discovered that a nurse, who did not check to determine whether it was safe for the resident to go outside, allowed the resident to go outside on his own. The nurse claimed that he did not hear any waderguard alarms go off when the resident left the building. Thankfully, the resident was found safe at a bus-stop about a half-mile from the facility, wearing his wanderguard on his ankle. Upon inspection, it was discovered that the wanderguard device was past its expiration date, so the anklet was swapped out for a newer device not yet expired.

This state determined that allowing the resident to leave the nursing home placed the resident in immediate jeopardy. Immediate jeopardy is a situation in which the nursing home’s non-compliance with one or more requirements has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident.

Click here to read the full report.