Nearly 1,000 nursing home residents exited without supervision
The man was found in the middle of the night with a bloody face, bloody clothes and no pants, in the front yard of a house in Jacksonville that wasn’t his. A 2017 report from the Centers for Medicare and Medicaid Services (CMS) indicated that the 72-year-old man, whose name was redacted, had bruising, swelling, an infected left eye and scratches on his arms. Medical examiners also noted he appeared to be the victim of an assault, had obvious head trauma and had fallen.
There were no known suspects or witnesses. Nobody noticed him leaving the nursing home, Ascension Living St. Catherine Labouré Place, which he checked into just three days prior. Nobody at the facility was aware the resident was missing until the hospital notified his daughter, who contacted the nursing home.
The daughter, whose identity in the report is also redacted, said she knew staffers at the nursing home weren’t telling the truth when they said they last saw him at 12:30 a.m., because she had the Emergency Medical Services report indicating that he was picked up 3.5 miles away from the facility at 12:02 a.m. The resident also had a known history of exit-seeking behavior, and the door code for the nursing home was posted next to the keypad.
He didn’t remember how he got out of the facility. Having been diagnosed with Alzheimer’s, he didn’t have the mental faculties to fend for himself.
He could’ve died. And he’s far from alone.
Between 2017 and 2021, there were 993 instances of residents of Florida nursing homes exiting their facility without proper authorization or supervision, according to Florida Agency of Health Care Administration records. On average, that’s almost four “elopements” — as they’re referred to in the medical community — each week.
Florida nursing homes care for roughly 71,000 residents at any given time, according to the Florida Health Care Association, making elopements relatively rare. But they can be extremely dangerous for people living with dementia, said Ronald Petersen, the director of the Mayo Alzheimer’s Disease Research Center.
People living with dementia can struggle to monitor where they are, why they’re there, who’s around them, what people are saying and how people are reacting, he said. They may think they’re fine and not realize that their brain is severely impaired, or they might feel confused, uncomfortable and anxious. This can lead to wandering, Petersen said.
“It is an important issue,” he said. “And it’s one that long-term care facilities are very mindful of and cautious about [and] careful about because it can lead to some dangerous situations.”
WUFT reporters analyzed more than 100 elopements detailed in police reports and CMS deficiency reports. These records included incidents of cognitively impaired residents wandering miles away from their facility through heavily trafficked, multi-lane highways, active railroads, 90-degree heat, various waterways and/or hazardous terrain.
Callie Pearce, for instance, was 77 years old and diagnosed with dementia when she exited the Courtyards of Orlando Care Center in March 2021, according to a CMS report.
A police report indicates that a helicopter unit and bloodhounds were dispatched to help with the search. After seven hours, Pearce was found 5.2 miles away from the facility, walking against traffic at the interchange ramp between Interstate 4 and the East/West Expressway.
The officer who found her, John Psomas, described it as one of the highest ramps in the Orlando metro area, as noted in the CMS report. It varies from four to 12 stories high, and the Orlando area itself is considered the nation’s most dangerous for pedestrians, according to the Orlando Sentinel. Pearce told Psomas that her feet and side hurt due to the long walk, according to the CMS report.
CMS inspectors determined she would have “traversed two major thoroughfares and intersections that were heavily trafficked.” They weren’t able to figure out how she managed to get onto such an elevated highway, which was also under construction at the time.
An administrator at the nursing home declined to comment to WUFT about Pearce’s elopement.
The WUFT analysis also found a couple of elopements that resulted in the death of a resident. And that’s only from the CMS reports that are available to the public. Under state law, the remaining elopements, roughly 900, must be kept confidential unless AHCA determines that they warrant disciplinary action.
Holding nursing homes accountable
Federal and state laws guarantee nursing home residents the right to be free from abuse, neglect or exploitation. But it’s not clear how dangerous an elopement must become to rise to this standard.
In multiple instances, AHCA failed to document or penalize malpractice in nursing homes even when it endangered at-risk residents like Ricky Holly, now 60, who eloped in 2017 from the Gainesville nursing home North Florida Speciality Care.
According to a report from the Alachua County Sheriff’s Office, nurse Rene Tabino reported him missing on Christmas Day and told police that Holly was suffering from high ammonia levels. This left him disoriented and confused, so Tabino was worried he might wander into traffic or otherwise accidentally hurt himself.
Ricky Holly’s mother, Joann Holly, told police that when he was in this condition, which she compared to dementia, he seemed to have the mental capacity of a child and was clueless of his surroundings. She was scared to death, she said.
“I thought he was drowned in that little pond close to the rehab place,” Joann Holly said.
Ricky Holly was also an alcoholic with several liver diseases, and Tabino said that alcohol could make his ammonia levels even worse. Moreover, the medication that doctors prescribed for his ammonia condition had defecation as a side effect.
Gainesville police officer Christopher Dasher noted that Ricky’s bed and clothes were heavily stained with fecal matter and seemed to have been there for several hours, if not several days. This, in addition to what the officer described as a “nonchalant attitude from the facility staff,” led Dasher to believe that Ricky’s absence might be more severe than law enforcement first understood, according to the police report.
North Florida Specialty Care could not be reached for comment.
The police report indicates Ricky Holly was last seen around 11 p.m. with a group of family members who were visiting another resident, and the nurse who saw him didn’t realize who he was at the time. But Joann Holly said that they don’t allow visitors that late, and a nursing home staffer said visiting hours today are between 8 a.m. and 8 p.m.
“So why let somebody walk out the door right there in front of them?” Joann Holly said. “I can’t understand that to this day.”
When Ricky Holly was found two days later, several miles away from the nursing home, he was confused and had soiled himself but was not injured, the report indicated.
AHCA public records show Holly’s elopement did not result in a deficiency for the nursing home, and WUFT obtained police reports detailing several other elopements that were unaccounted for in CMS deficiency reports:
Lamar Davis, 64, suffered from dementia-related issues and eloped from Tallahassee Living Center in July 2020, according to a report from the Tallahassee Police Department. Davis was found uninjured in the parking lot of the Florida Department of Law Enforcement, unsure of where he was going or what he was doing.
Gary Berwaldt, 49, suffered from dementia and an unspecified mood disorder when he eloped from Park Meadows Health and Rehabilitation Center in July 2017. Berwaldt exited the Gainesville nursing home through the back door, climbed over the fence and trespassed onto an event venue property. He was found by a police officer in the front of the building with no shoes and a laceration on his heels. After a medical evaluation, Berwaldt was transported to the emergency room.
- George Macdonald, 81, suffered from mild dementia and eloped from Signature Healthcare in September 2018. This was his first successful elopement after a series of attempts. After roughly three hours, Macdonald was found by a Gainesville law enforcement officer at a Carrabba’s restaurant 1.5 miles away, intoxicated and exposing himself. He was then transported to the hospital due to dehydration
None of these nursing homes could be reached for comment. WUFT spent two months corresponding with AHCA over dozens of emails and phone calls, but the agency would not explain why elopements like these went unpenalized or detail how dangerous an elopement has to be to warrant a deficiency. In a statement, a spokesperson said, “If the Agency determines through an investigation that an Assisted Living or Nursing Home facility did not take appropriate actions to correct/prevent a resident elopement, then the Agency will cite the facility for a deficiency.”
Finding the familiar
Brandi Hackett, manager of Support Services at the Lewy Body Dementia Association, said people living with dementia are not always aimlessly wandering. They may have a goal and can be steadfast in their effort to achieve it.
She said she remembers a nursing home resident with a dementia-triggering head injury who constantly wanted to go home and kept trying to leave the facility. Consequently, the woman was required to wear a WanderGuard, a device that functions similarly to a house arrest ankle monitor, Hackett said.
Over time, though, the woman realized that it would activate a locking mechanism whenever she approached doors in the facility. So the resident kept cutting it off, determined to get out, Hackett said.
“If any of us moved from our home right now and were placed into a secured unit, many of us would try to find a way out, especially if we weren’t granted outside privileges,” Hackett said. “If we had a condition like dementia, where we didn’t know who any of these people were, we don’t know the environment [and] we don’t know the people trying to care for us, it makes sense just from a psycho-emotional standpoint that people may want to find home or find familiar.”
Steven DeKosky, deputy director of the McKnight Brain Institute at the University of Florida, explained that for people living with Alzheimer’s, a degenerative disease that causes dementia, their concept of “home” isn’t always clear. They may want to go home while “standing in the house they have lived in for 30 years,” DeKosky said. And in fact, six in 10 people who live with dementia wander from their home at least once, according to the Alzheimer’s Association.
Tailoring dementia care to the individual
Some medical professionals believe that a lack of person-centered care can provoke more elopements.
Janet Steiner was an active dementia trainer for 15 years through the National Council of Certified Dementia Practitioners, prior to her retirement in 2020. She emphasized that people living with dementia still have their emotions intact and, despite memory issues, still carry past experiences that can affect them in the present. She added that when caring for people living with dementia, nursing home staffers need to intimately understand how specific words and phrases rooted in someone’s past can trigger certain feelings and behaviors, an important component of person-centered care.
These triggers can lead to elopement, Steiner said. She gave an example of someone living with dementia who had strict and controlling parents growing up. Saying things like “no,” “don’t do that” or “you can’t” may remind them of their parents and make them want to leave, she said.
“If they’re hearing a lot of negative language, they’re going to get very discouraged,” Steiner said. “They’re going to want to escape that kind of talk.”
But when used correctly, these triggers can also help people living with dementia. Steiner told a story about a CNA who was trying to drag a resident with dementia into the bathroom because she had been instructed to clean him up and get him dressed for the day.
“He was shoving her and causing a horrible fracas,” Steiner said. “She was likely to get hurt, and he was certainly likely to get hurt.”
The director of nurses had read his chart, though. She knew a little about him and his history, Steiner said.
“She looked at the man, and she says, ‘It’s time for a s—, shave and a shower!’ And he marched right into the bathroom,” Steiner said.
The resident had been a high-ranking military man; he was used to getting ready in the morning with that three-step routine, so he responded well to that, Steiner said.
Though this approach is effective, it takes a tremendous amount of patience, she added. And nursing home staffers often have deadlines for completing their tasks.
“That’s a real problem in the staffing and in the scheduling is they want it boom, boom, boom, done on a schedule,” Steiner said. “Dementia people don’t live on a schedule.”
That’s why programs like the Eden Alternative are more expensive but more effective: They allow residents to live at their own pace, instead of imposing a schedule, Steiner said.
This form of care can also alleviate elopements by encouraging more long-term relationships with residents of nursing homes. The CMS State Operations Manual for inspectors of long-term care facilities indicates that staffing sufficiency can be linked to elopements. And organizations that have implemented the Eden Alternative boast a turnover rate of 35%. By contrast, the turnover rate for nursing homes nationwide is 94%, according to a 2021 study in the Journal of Health Affairs.
Researchers explain that the common perception is that a high turnover rate can indicate “low compensation, poor working conditions, and few opportunities for advancement.” This, according to the study, can worsen the quality of care in multiple ways: Most notably, new staff members won’t be as familiar with the facility’s residents. It naturally follows that they also would be less familiar with the triggers of residents who live with dementia, allowing for more elopements.
Section 400 of the Florida Statutes requires of long-term care facilities a minimum of two elopement drills every year. But Teepa Snow, a North Carolina-based dementia researcher and practitioner, said that’s not enough.
Facilities practice fire drills every month; they don’t all practice elopement drills every month. Yet there are more elopements than fires, Snow said.
“We manage our fire. We manage the sprinkler system. We have all kinds of things. We have that system pretty well established,” Snow said. “Eloping? We just hope it doesn’t happen.”
Steiner said CNAs need more training in dealing with dementia, both in the nursing home and school.
“A lot of times when I go in to do a training, I might get an hour. I might get two hours,” she said. “Well, it’s a lot more complicated than that to care for someone with dementia.”
Steiner also said she asks nurses how much they learned about dementia in studying to become a CNA, and most of them say they didn’t learn anything.
“In CNA school, they’re learning how to give a bath, how to help with changing somebody while they’re in bed, change a diaper, et cetera,” Steiner said. “But they’re not learning about how to communicate with someone with dementia.”
Rebecca Gomez, having worked as a CNA in the memory care unit of a nursing home for a year, said CNAs are not required to receive dementia training to be certified. The amount of dementia training they receive is left up to the nursing homes who employ them, she said.
The amount of training that nursing home workers receive is an issue that extends beyond the residents, nurses and administrators of these facilities. Lawmakers play an important role.
In February, the Biden administration laid out its plans for improving safety and quality of care in nursing homes nationwide. Among other things, the proposed reforms include a crackdown on poorly performing facilities, an increase in funding for CMS inspections and a minimum staffing requirement.
Meanwhile, Florida Gov. Ron DeSantis recently signed legislation that would reduce the amount of time that CNAs are required to spend with each resident, from 2.5 hours per day to 2 hours. State law still mandates that CNAs and licensed nurses provide a combined weekly average of 3.6 hours of direct care per day, so the bill would require nursing homes to supplement the remaining deficit with direct care from their pick of a wide variety of professions, from pharmacists, therapists and dentists to paid feeding assistants, according to an analysis from the Florida House of Representatives’ Health & Human Services Committee.
Supporters of the bill, like the Florida Health Care Association, argue that Florida’s staffing standards are outdated and don’t address mental health needs and social services. They also argue that amid staffing shortages, CNAs are the hardest jobs to fill and force nursing homes to accept fewer residents.
“Florida’s nursing homes staffing standards were created a few decades ago, back in 2001. … There haven’t been any significant changes to the staffing requirements since then,” said Kristen Knapp, the senior director of strategy and communications at FHCA. “This bill, what it does is it takes into account the changing needs of our residents. … It gives facilities flexibility in terms of their staffing so that they can staff to meet the residents’ needs.”
WUFT spent more than a month trying to contact state Rep. Lauren Melo, R-Naples, through more than a dozen phone calls and emails. She initially agreed to an interview, canceled at the last minute and could not be reached for comment thereafter.
Advocates for elders and health care workers strongly oppose the bill. In a joint panel hosted March 24, members from the American Association of Retired Persons and the 1199SEIU, accompanied by state Rep. Carlos Guillermo Smith, D-Orlando, argued that these mental health and social services were already guaranteed to residents via a doctor’s order and that the bill only affords nursing homes more flexibility in cutting costs. A spokesperson for 1199SEIU said the bill would give CNAs less time to do the same amount of work, resulting in more CNAs losing their jobs and longer wait times for residents to receive basic needs, like being fed, bathed, helped out of bed and brought to the restroom.
“This only ‘modernizes’ care if you mean seniors will get less tomorrow than they do today,” said Roxey Nelson, the vice president of 1199SEIU. “Nursing homes are owned by large venture capital companies that have one prime directive: to make as much money as possible. It’s outrageous they’re allowed to do this with our own tax dollars at the expense of elderly patients and their low-wage caregivers.”
While this bill may have a meaningful effect on staffing and, consequently, elopements, there may be something even bigger coming down the pipeline.
According to the Alzheimer’s Association, almost nine out of 10 physicians say they expect to see an increase in people living with dementia during the next three years, and only half think the medical community is prepared for this steep increase in demand.
Steven DeKosky said this incoming surge in dementia is primarily due to the aging of people from the Baby Boomer generation, who are already in or entering their 70s.
“We absolutely don’t have enough social workers or resources within a community to take care of them,” DeKosky said. “So Medicare is in trouble if we don’t find something in the reasonably near future.”
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