The attack was severe enough that law enforcement arrested Resident #2, who will not be returning to the facility.
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Federal inspectors found the facility failed to follow its own fall prevention plan for the resident.
The employee entered the security code, disarmed the door alarm, and opened the door.
Federal inspectors found the facility failed to protect residents from physical abuse by other residents.
The elopement occurred at 2:45 p.m.
Federal inspectors observed the infection control failures during a complaint investigation at Benefis Senior Services - Grandview on August 12.
Both residents have dementia and depend on staff to help them participate in programs.
During assessments, she disclosed her use of drugs and alcohol to the facility's Social Services Director.
Staff L, a certified nursing aide with a staffing agency, was assisting residents with transfers on her second day at the facility.
The medication error wasn't discovered until July 19, when someone finally noticed the discrepancy.
The incident came to light during a federal investigation into bruises found on the resident.
Each time, she reported severe pain.