A 78 year old resident jumped out of a second-story window in a New York nursing home on June 1, 2021. The incident occurred several hours after the resident was admitted to the facility.
At the time of admission to the facility, staff report that he was anxious, confused, agitated, and wandering. A device was placed on the resident’s ankle to alert staff if he tried to leave the facility. The facility did have safety latches on their windows to prevent the windows from being opened more than six inches. However, the resident was able to obtain a mop from a maintenance room, and use the mop handle to break the safety latch. The resident then opened the second-floor window and jumped.
He was found lying in the grass outside of the facility by an employee of the nursing home. He had blood in his mouth and complained of a sore back, and was transported to a hospital.
The incident immediately launched an investigation by the Department of Health (DOH), and the facility was cited for Immediate Jeopardy. The DOH did not provide any further information regarding the incident, and at this time since is still investigating. The facility did not provide any further details at this time.
The nursing home was recently fined $2000 for failing to quickly notify residents of new COVID-19 cases within the facility. In November 2020, 121 residents and 75 employees contacted COVID-19. Forty-eight residents died due to COVID-19 at this facility.
Issue:
All facility leaders should be well versed in Life Safety Code requirements. Safety of the residents should always be the top priority. Safety rounds should be conducted routinely by facility leadership to identify life safety risks and address findings immediately. The Life Safety Code requirements should be reviewed by facility leaders who must ensure that staff are aware of and meeting the requirements.
Discussion Points:
- Review the most current Life Safety Codes and ensure that your building meets those requirements. Update your Life Safety documents if needed.
- Ensure that the facility Maintenance Director and staff are aware of current Life Safety Codes, including the importance of keeping doors to supply closets and equipment storage areas locked, and provide training as needed. Document that these trainings occurred, and file the signed documents in each employee’s education file.
- Periodically conduct environmental rounds audits to ensure that Life Safety codes are being followed.
