According to a New York State Department of Health citation report, staff members of the Suffolk County Center for Rehabilitation and Nursing center, a 10-bed nursing home located in Patchogue, Long Island failed to monitor a patient who was found dead in a bathroom with a seatbelt around his neck. The report indicated that the patient, who had turned blue, “was found unresponsive without pulse and respiration–no sign of life.” The resident, who suffered from dementia and was required to wear a seatbelt in his wheelchair, was trying to get out of his wheelchair in order to use the toilet. However, while attempting to slip under his seatbelt, the restraint became wrapped around his neck, strangling him to death.
Investigators reported that because the patient had a history of wandering, his care plan required that he wear a seatbelt in his wheelchair. If the patient tried to undo the seatbelt, an alarm would sound. In addition, his care plan required that an assigned staff member check on him every 15 minutes and document that the check was performed. On July 15, 2013, a certified nursing assistant was assigned to watch the patient. At 1:15 p.m., the CNA left the resident in the dayroom which was being monitored by another staff member. The CNA told investigators that he thought that the dayroom supervisor would watch the resident.
At 1:28 p.m., the patient was caught by a surveillance camera wheeling himself out of the dayroom and a nurse placed him in front of the nursing station. The nurse stated that he was unaware of the fact that the resident needed to be monitored every fifteen minutes. At 1:33 p.m., video footage showed the resident wheeling himself towards the bathroom, which staff members claimed to have locked. At 2:12 p.m., another resident of the facility found the patient in the bathroom with the seatbelt around his neck. After the resident alerted staff members, a code blue was called. At 2:20 p.m., a nurse practitioner noted that the resident had died. The DOH report concluded that staff members failed to follow the patient’s care plan by not monitoring the resident every 15 minutes.
The “Nursing Home Compare” website documents that the Suffolk County nursing home has a history of violations for providing poor care. The DOH issued 18 deficiencies; the average number of deficiencies for other New York nursing homes is 5.4. In addition, in June 2013, inspectors issued $36,661 in fines against the facility for numerous violations that placed residents in immediate jeopardy of suffering harm or injury. Overall, the nursing home was rated below average and received a much below average rating for its health inspection record. Moreover, 46 percent of the residents showed symptoms of depression; the average percentage of depressed patients in other New York facilities is 11.6 percent.
