Page Rehab: Resident Dies After Elopement Failure - FL

Resident #999's son had warned the facility his father was paranoid and would "try and find a way out." The Director of Nursing said she didn't feel the resident needed increased supervision.

The vulnerable resident was admitted following hospitalization for altered mental status. Two physicians had signed statements declaring he lacked capacity to make healthcare decisions due to advanced stage dementia and confusion. His diagnoses included unspecified dementia, psychotic disturbance, major depressive disorder, anxiety, and bipolar disorder.

Three separate elopement evaluations determined he was not at risk for wandering. Each time, staff failed to check off risk factors including psychiatric history, expressed desire to leave, and attempted elopement.

The psychiatric nurse practitioner documented the resident exhibited no behaviors or psychotic symptoms during nine visits between his admission and the incident. But on the day before his escape, everything changed.

At 10:56 a.m., the resident's son called the facility. His father had phoned him saying he was "under attack" and needed immediate evacuation. The son told staff his father had been diagnosed with bipolar disorder, paranoia, and schizoaffective disorder. He had previously been involuntarily hospitalized and prescribed Risperidone for psychotic symptoms.

The psychiatric nurse practitioner saw the resident that day and found him "agitated, upset" with "disorganized" thought processes. She documented he was "unstable requiring medication changes" and restarted the antipsychotic medication.

That afternoon at 5:23 p.m., Fort Myers police called the facility. Resident #999 had contacted them requesting evacuation because he was "in danger of the war and needed evacuation." Officers arrived and spoke with him for five minutes before leaving.

Nobody updated his elopement risk assessment. The care plan wasn't revised to address his acute behavioral changes. Staff weren't told to increase supervision.

The next day, Licensed Practical Nurse Staff D went to administer medications at 4:15 p.m. and couldn't find the resident. He searched room by room with a nursing assistant. At 4:35 p.m., they notified the supervisor, who called a code pink for missing resident.

The resident's wheelchair was found outside by the Ford Unit. At 8:15 p.m., a detective called to report Resident #999 had been found deceased in a bar parking lot down the road from the facility.

Multiple staff members had seen warning signs but failed to act. The maintenance assistant observed the resident outside around 3:30 to 4:00 p.m., in an area not visible from the front desk. When he tried to bring the resident inside, the man refused. The maintenance worker left him there and told no one.

"I did not try to get him to go inside," the maintenance assistant told investigators. "I did not bother because he gets very agitated and would swear at you."

Licensed Practical Nurse Staff I saw the resident sitting outside from a window but didn't report it to anyone.

Unit Manager Staff B overheard the resident asking police officers to remove him from the facility, saying he was in danger. She didn't relay this information to direct care staff or order increased supervision.

"She did not see a reason to place the resident on one-to-one supervision or every 15 minutes checks just because he called the police one time," investigators wrote.

The Director of Nursing admitted she knew about the son's concerns and the police visit but didn't tell staff. She didn't feel the resident needed increased supervision despite his psychiatric history and expressed intent to leave.

"She verified the resident's elopement risk was not re-evaluated despite knowledge of the psychiatric history and expressed intent to leave the facility," the inspection report states.

The facility had no policy specifying which residents could come and go freely. The Administrator said Resident #999 wasn't considered an elopement risk and "enjoyed the freedom to get fresh air."

But the family had crucial information the facility never obtained. The resident had previously eloped from an assisted living facility, trying to get back to Missouri. That incident led to his involuntary psychiatric hospitalization.

"The facility was not aware of the resident's elopement history," the Director of Nursing acknowledged.

The son's warnings proved prophetic. "I told them he would try and find a way out of the facility," he told investigators. "He was a flight risk and wanted to elope."

Communication failures plagued the facility's response. The Licensed Practical Nurse working the day shift said no one informed him of the resident's mental status changes or medication updates. He learned about the police visit through "word of mouth."

The Certified Nursing Assistant said she heard about the police call but no one told her to supervise the resident. "If she had seen him outside she would have brought him back in as no resident should be left unsupervised outside," she told investigators.

The Social Service Director, responsible for updating care plans for behavioral changes, said nobody told her about the son's concerns or the police visit. No clinical alert was documented in the electronic record about the resident's paranoid behavior and intent to leave.

Even after the tragedy, the Administrator deflected responsibility. He told investigators the resident "died of natural causes" and questioned why police didn't recommend more supervision.

"Why didn't the police tell us that he needed more supervision?" the Administrator asked. "They thought he was fine."

The facility's investigation following the death failed to examine why staff didn't reassess the elopement risk when the resident exhibited paranoid behavior and voiced intent to leave. Their corrective actions didn't address the need to document new behaviors that could lead to elopement.

Federal inspectors found additional medication safety violations during their visit. Pills were left unattended on bedside tables and scattered on floors. One resident had a potassium pill in a plastic cup, waiting for someone to break it in half. Another resident's inhaler was left on a bedside table while he was out of the room.

A housekeeper standing near the sitting room entrance ignored a large white pill on the floor until a nurse was notified to remove it.

The inspection resulted in immediate jeopardy citations, the most serious level of violation. Inspectors determined the facility's failures created "a likelihood of unsafe wandering and elopement of cognitively impaired, confused residents which could result in serious harm, serious injuries or death."

The resident's son had made his father's vulnerability clear in his final conversation with staff. His father was hallucinating, believing people were going to kill him, and desperately wanted to escape. The facility had every tool needed to prevent the tragedy that followed.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Page Rehabilitation and Healthcare Center from 2025-01-10 including all violations, facility responses, and corrective action plans.

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