Facility fined $552,000 for resident elopement and death

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A skilled nursing facility that ignored warning signs of potential resident elopement and later made medical mistakes near the time of a wanderer's death, was fined $552,109, according to a recently released report.

The Washington Department of Social and Health Services fined Forest Ridge Health and Rehabilitation Center for the October incident and recently released investigation details.

According to the official report, the resident left the facility sometime between 12:30 a.m. and 2 a.m. and was found lying in the parking lot at 2:25 a.m. After being taken to the hospital, he returned to the facility four hours later. The resident died that afternoon, with report authors saying that staff made critical mistakes with his care, although the cause of death was redacted from the report, according to local news reports.

Forest Ridge is a 98-bed long-term care and short-term skilled nursing facility in the Seattle suburb of Bremerton.

State investigators found through interviews with staff members that the resident was not noted as a risk for elopement and allowed to roam the facility freely, even though he had hallucinations and delusions, said he wanted to leave the facility, and frequently sat in the lobby looking out the front door.

The report further states that when the resident returned from the hospital, he had low oxygen blood levels. The Forest Ridge staff did not supply enough oxygen flow to his air mask, however, which caused an excess of carbon dioxide in his blood, investigators wrote. In addition, the resident was observed breathing quickly and staff noticed he had an abnormal sound coming from his lungs, according to the report. He was given intravenous fluids, which eventually built up in his lungs, authorities said.

The provider reported the incident immediately, but an internal investigation didn't take place until 15 days later, regulators said.

The State Social and Health Services investigation determined that there were not enough safeguards to prevent residents from leaving, and that there was no clear way for residents to enter the building after they have left at night. Concerns included no alarm to warn staff when a door was opened, no cameras monitoring exits, doors that could be opened from the inside but locked from the outside, and a doorbell that was hard to see.

The facility installed door alarms and made doorbells more visible by mid-January.

"We realized areas for improvement and immediately enhanced our building security and provided further education for our staff both on building safety and providing respiratory assessments. As a result, our center is currently in full regulatory compliance,” Forest Ridge officials said in a statement.