LEHIGH ACRES, FL - Federal inspectors found serious safety violations at Lehigh Acres Health and Rehabilitation Center after a resident with Alzheimer's disease walked out of the facility unsupervised and was found 16 miles away at a downtown bar, according to a state inspection report.
Critical Supervision Failures Led to Patient Elopement
The August 2024 incident began when Resident #1, a man with severe cognitive impairment and Alzheimer's disease, walked into the facility's front lobby carrying a bag of clothes over his shoulder. Despite multiple warning signs about his mental state and wandering behavior documented by staff, the facility failed to implement adequate supervision measures that could have prevented his departure.
The resident had scored a 3 out of 15 on the Brief Interview for Mental Status assessment, indicating severe cognitive impairment. Multiple healthcare professionals had documented his confusion, poor judgment, and repeated statements about wanting to go home. A physical therapy assistant noted the resident "was confused but hid it well" and expressed concern about improving his physical abilities due to his severe cognitive limitations.
On the evening of August 16, 2024, the resident sat in the lobby dressed like a visitor with a bag over his shoulder. When the receptionist asked if he was a resident or visitor, he responded that he was a visitor and walked out when the door was opened for another person leaving. The receptionist, who had never seen him before, allowed him to leave without verification of his identity or requiring him to sign out.
Staff members were not aware the resident had left until more than an hour later when a certified nursing assistant discovered he was missing during evening rounds. The resident had walked approximately 75 feet to a busy six-lane road, boarded a public bus, and traveled 16 miles to downtown Fort Myers where he was eventually found outside a bar.
Inadequate Risk Assessment and Care Planning
The facility's initial assessment process showed significant gaps that contributed to this dangerous incident. Upon admission on August 7, 2024, nursing staff evaluated the resident's elopement risk and scored him as not at risk for elopement, despite documenting that he "wanders, but has NEVER eloped."
This assessment proved inadequate as warning signs emerged almost immediately. Within days of admission, multiple healthcare professionals documented concerning behaviors:
- A speech language pathologist noted changes in cognitive function and safety awareness - The attending physician observed cognitive impairment during multiple visits - A psychiatrist documented severe confusion, poor judgment, and disorientation - Nursing staff recorded that the resident was "wandering and doesn't know where he is"
Despite these documented changes in the resident's condition and behavior, the facility failed to reassess his elopement risk or implement additional safety measures such as a wander alarm bracelet. Licensed practical nurse Staff A later acknowledged that placing such a device on the resident would have triggered an alarm when he attempted to leave, potentially preventing the incident entirely.
The medical consequences of failing to properly supervise residents with dementia can be severe. Individuals with Alzheimer's disease and related dementias often experience disorientation, impaired judgment, and memory loss that compromises their ability to navigate safely. When such residents leave a care facility unsupervised, they face significant risks including traffic accidents, exposure to weather elements, becoming lost, and being unable to seek help or identify themselves.
Communication Breakdowns Among Staff
The inspection revealed concerning communication failures among nursing staff on the evening of the incident. Licensed practical nurse Staff B was receiving shift report when she observed the resident walking toward the lobby around 7:20 p.m. She instructed a certified nursing assistant to ask the resident to return to his room but continued with report duties rather than ensuring compliance.
When questioned about the resident's whereabouts at 7:30 p.m., Staff B told the nursing assistant that the resident was "walking around" rather than conducting an immediate search. It wasn't until 8:45 p.m. that staff realized the resident was actually missing and began searching the facility and surrounding areas.
This communication breakdown highlights systemic issues in how the facility managed residents with cognitive impairment. Proper protocols would have required immediate verification of the resident's location and continuous supervision given his documented confusion and wandering behaviors.
Industry standards for dementia care emphasize the importance of structured supervision protocols, regular safety assessments, and clear communication among all staff members. Facilities caring for residents with Alzheimer's disease typically implement multiple safety layers including wander alarms, secured units, frequent check-ins, and trained staff who can recognize and respond to exit-seeking behaviors.
Delayed Reporting to Authorities
In addition to the supervision failures, inspectors found that the facility violated federal reporting requirements by failing to notify state authorities within the required timeframe. The preliminary report was submitted four days after the incident, when regulations require immediate notification of potential neglect allegations.
The five-day follow-up report was submitted seven days after the facility became aware of the neglect allegation, exceeding the required five-day deadline. During interviews, the facility administrator acknowledged these reporting violations. Timely reporting is critical for ensuring proper investigation of incidents and implementing corrective measures to protect other residents.
Medical Professional Assessments Confirm Safety Concerns
Healthcare professionals who treated the resident unanimously agreed he was not safe to leave the facility unsupervised. The attending physician stated that "anything bad could have happened to the resident" and that he "could have been seriously harmed."
The speech language pathologist noted that the resident's combination of severe cognitive impairment with good physical mobility created a particularly dangerous situation. The resident's confusion, poor decision-making ability, and severely impaired short-term memory made independent community navigation extremely unsafe.
A psychiatrist who evaluated the resident found him "very depressed, crying and confused" with significant disorientation and inability to provide basic information about himself. Emergency room physicians who treated the resident after he was found documented that he remained confused, didn't know his location, and believed he was in Maine rather than Florida.
Family Concerns and Facility Misrepresentation
The resident's daughter revealed that she had specifically requested placement in a memory care unit after being told by the hospital case manager that the facility had such a unit. She discovered after admission that no secured memory care unit existed at the facility, contrary to what she had been told.
When she expressed safety concerns to nursing staff, she was reassured that "they monitor their residents all the time." The subsequent elopement demonstrated that this monitoring was inadequate for residents with severe cognitive impairment and wandering behaviors.
Additional Issues Identified
Inspectors documented several other compliance concerns during their review:
- Inadequate visitor identification procedures that allowed confused residents to be mistaken for visitors - Lack of systematic reassessment protocols when residents showed changes in cognitive status or behavior - Insufficient training for reception staff on recognizing and managing potential elopement situations - Gaps in care plan updates despite documented changes in resident condition
Facility Response and Corrective Measures
Following the incident, the facility implemented several immediate safety measures including comprehensive audits of all 119 current residents, with particular focus on the 43 residents who had cognitive impairment scores below 13. Staff received additional training on recognizing and preventing unsafe wandering, and the facility updated its elopement risk assessment procedures.
The facility also reinstated visitor identification stickers that had been discontinued during the COVID-19 pandemic and updated elopement risk binders located at nursing stations and the reception desk. These corrective actions were verified by inspectors before the immediate jeopardy status was removed on August 24, 2024.
The resident was eventually transferred to a different skilled nursing facility with a secured memory care unit, highlighting the importance of appropriate placement for individuals with dementia who exhibit wandering behaviors. This incident underscores the critical need for specialized dementia care programs and proper risk assessment protocols in long-term care facilities.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lehigh Acres Health and Rehabilitation Center from 2024-08-24 including all violations, facility responses, and corrective action plans.
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