Health Department Takes Action Against Queens Nursing Home

State Investigators Cite Immediate Jeopardy Following Death of Resident

ALBANY, February 11, 2004 — The New York State Department of Health (DOH) today took action against Bishop Charles Waldo MacLean Episcopal Nursing Home in Far Rockaway, New York for significant, widespread lapses in policies and protocols to prevent residents from wandering within the facility and eloping.

As part of its ongoing investigation, the DOH today cited the Queens nursing home for the federal government's most serious violations, known as Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), following the death of an elderly resident on February 4, 2004. The resident was found on the facility's rooftop several hours after she was reported missing from the home.

The Department has notified the nursing home of these egregious deficient practices and is requiring the administrator to take immediate action to correct the violations to ensure the safety and well-being of residents.

The DOH's investigation, which includes seven consecutive days of on-site monitoring, will continue, with additional citations and potential enforcement action to be taken as the State’s surveillance progresses. The home may face penalties including maximum fines allowable under the law ($2,000 per violation) once the investigation is complete.

The DOH has referred the nursing home to the federal Centers for Medicare and Medicaid Services for denial of payment for new admissions under the Medicare and Medicaid program. As a result, the nursing home will not receive payment for new admissions to the home until all violations are corrected, including immediate rectification of the IJ and SQC violations. As part of this process, the nursing home will be required to submit a written plan of correction to the DOH for approval after the agency's full inspection report is issued. Once the plan of correction is approved, the DOH will re-inspect the home after the corrections are fully implemented to ensure the safety of residents.

The nursing home must immediately address the following violations cited today:

  • The failure to conduct a thorough search of the facility when door alarms initially sound, signaling the potential for a resident to have left the unit through an exit door to a stairway.
  • The failure to develop care plans to address the potential risks for residents wandering within the facility and eloping. The nursing home failed to implement interventions to ensure the safety of all residents who are at risk for wandering within the facility and eloping.
  • The failure to thoroughly survey and investigate areas where the door alarms sound, posing a risk of Immediate Jeopardy to all residents residing in the nursing home.
  • The failure to account for the general whereabouts of all residents at risk for eloping.
  • The failure to fully train staff to effectively supervise residents who exhibit signs of dementia, confusion and a history of wandering. The staff was unable to identify those residents at risk for elopement or what interventions are in place to prevent them from eloping.