BOYNTON BEACH, FL - A severely cognitively impaired resident at Isles of Boynton Nursing and Rehab Center fell approximately 20 feet from a second-floor window on Christmas Day after staff failed to provide adequate supervision, resulting in serious head and spinal injuries that required emergency hospitalization.
Critical Supervision Failure Led to Preventable Accident
The incident occurred on December 25, 2024, between 7:15 and 7:20 AM when Resident #1 removed the right window panel from his room's window frame and fell to the ground in a narrow area between the building and a palm tree. The 20-foot fall caused multiple serious injuries including a new acute left subdural hemorrhage, intraventricular bleeding, and a compression fracture of the third lumbar vertebra.
State inspectors found that the facility's staff had failed to recognize and respond appropriately to clear exit-seeking behaviors exhibited by the resident throughout the night shift. Despite the resident having a documented history of attempting to leave the building and being placed on one-to-one observation just five days earlier, nursing staff did not implement proper supervision protocols when warning signs emerged.
Licensed Practical Nurse Staff A, who was working the overnight shift, told investigators that she observed the resident at an exit door where the alarm was ringing at approximately 6:15 AM - a clear indication of exit-seeking behavior. However, she only redirected the resident back to his room without implementing the facility's protocol for one-to-one observation. Staff A later acknowledged that "had she known Resident #1 had been exit-seeking prior to his being moved upstairs she would have placed him on 1:1 observation."
The medical consequences of this supervision failure were severe. Hospital records revealed the resident sustained a new small acute left subdural hemorrhage measuring up to 4 millimeters, along with bleeding in the brain's ventricular system. These types of brain injuries can cause increased intracranial pressure, altered mental status, and potential long-term neurological deficits. The compression fracture to his lumbar vertebra required treatment with a back brace and could result in chronic pain and mobility limitations.
Pattern of Unrecognized Exit-Seeking Behaviors
The inspection revealed a troubling pattern of staff failing to recognize and document exit-seeking behaviors throughout the night. Certified Nursing Assistant Staff C reported observing the resident wandering in hallways multiple times between 4:00 AM and 7:16 AM, but these observations were not properly documented or escalated.
Most concerning was that Staff A encountered two clear instances of exit-seeking behavior but failed to classify them as such. Beyond finding the resident at the exit door with the alarm sounding, she also reported that the resident followed her to a supply room and asked about the exit. In both cases, the resident was simply redirected to his room without additional safety measures.
Exit-seeking behavior in nursing home residents with cognitive impairment represents a significant safety risk that requires immediate intervention. These behaviors can escalate quickly and may indicate confusion, agitation, or an attempt to return to familiar environments. Standard nursing home protocols typically require one-to-one supervision for residents displaying such behaviors to prevent serious injuries from falls, wandering into unsafe areas, or in this case, attempting to exit through windows.
The facility's own care plan for the resident, created just two days before the incident, documented his severe cognitive impairment and inability to respond appropriately to questions. His Minimum Data Set assessment indicated he had wandering behaviors and was cognitively impaired to the point where he could not complete basic mental status evaluations.
Communication Breakdown During Shift Changes
A critical communication failure occurred during the shift change that may have contributed to the incident. Staff A stated that while she was informed the resident was "alert with confusion" and had been wandering between rooms during the previous shift, she was not told about his documented history of exit-seeking behaviors from December 20, 2024.
This communication gap violated fundamental nursing standards that require comprehensive handoff information about residents' behavioral risks and safety needs. In facilities caring for cognitively impaired residents, shift reports must include detailed information about recent behavioral changes, risk factors, and any special monitoring requirements.
The facility had previously recognized the resident's exit-seeking risk - he had been placed on one-to-one observation on December 20, 2024, after being observed trying to exit the building. However, when he was moved to the supposedly secure second floor that same day, the intensive supervision was discontinued based on the assumption that the secured unit would prevent exit attempts.
Inadequate Response to Early Warning Signs
The timeline of events reveals multiple missed opportunities to prevent the incident. Between 4:00 AM and 7:15 AM, staff documented that the resident was frequently out of his room, wandering in hallways, and attempting to flush his diaper down the toilet - all potential indicators of confusion and agitation that can precede exit-seeking attempts.
Licensed Practical Nurse Staff D, who responded to the emergency, found the resident on the ground with elevated vital signs consistent with trauma. "Staff D stated the resident's blood pressure was 200 over something" and his heart rate was approximately 116 beats per minute. She noted that while the resident was moving his arms, he was not moving his legs, raising immediate concerns about spinal cord injury.
The discovery that the resident was lying on top of a window screen helped staff realize he had fallen from the second floor. First responder Staff B described finding the resident "lying on the ground, on his right side, in the fetal position" in the narrow space between the building and landscaping.
Immediate Safety Measures and Systemic Changes
Following the incident, the facility implemented immediate safety measures including securing all windows with screws to prevent them from being opened or removed. Regional Maintenance Director inspected and reinforced windows throughout the facility, making them completely immovable while maintaining fire safety compliance through existing sprinkler systems.
The facility also initiated comprehensive staff retraining on recognizing exit-seeking behaviors and responding with appropriate supervision measures. All staff received mandatory education on abuse prevention, neglect prevention, elopement protocols, and behavior management, with no employees permitted to work until completing the training and passing competency tests.
Additional safety protocols implemented include daily elopement drills, enhanced screening of all residents for exit-seeking behaviors, and placement of signs at exit doors reminding staff to verify with nurses before allowing any resident to leave.
Additional Issues Identified
The inspection also revealed deficiencies in documentation practices, with staff admitting that their 20-minute monitoring checks of the resident were not properly recorded. The facility's communication systems for sharing critical safety information between shifts were found to be inadequate, contributing to the lack of awareness about the resident's exit-seeking history.
The incident prompted notifications to Adult Protective Services and implementation of enhanced quality assurance monitoring, with weekly audits of screening processes and supervision protocols. The facility's Quality Assurance Committee will oversee ongoing compliance monitoring until substantial compliance is achieved.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Manorcare Health Services Boynton Beach from 2025-01-08 including all violations, facility responses, and corrective action plans.
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