In January of 2022, a resident with dementia wandered out of her Assisted Living Memory Care facility in Iowa and ultimately, froze to death. The State of Iowa investigation uncovered that the resident wandered outside of the building at 9:30 p.m. the previous night. Her absence went unnoticed for eight hours plus even though the alarm system for the facility used to deter or prevent wandering, worked and did provide, multiple warnings. The complaint, filed a little over a week ago, is available here: lynne-stewart-death-petition
Per the complaint, the resident was admitted with diagnoses of Alzheimer’s disease, major depressive disorder and anxiety disorder. She was admitted to the facility in March of 2019 and transferred to a Memory Care unit (same facility) in August of 2019. The core Plaintiff argument is that the resident was a known wanderer and that the alarm systems the facility used consistently malfunctioned (false alerts) and as a result, staff became desensitized to the repetitive alarms and warnings.
- The outside door alarm that was not loud enough to be heard in common areas where staff members were working.
- Alerts also did not appear on iPads due to malfunctions previously known to the facility.
- Alerts did appear on office computers, but no staff members were assigned to monitor the computers during the 10 p.m. to 6 a.m. shift.
- Per State investigation, the facility’s executive director received multiple text message alerts when door alarms were triggered, but she slept through those alerts.
- The on-call registered nurse received a similar series of text alerts but failed to respond, stating that mechanical defects caused the alarms in the resident’s room to constantly trigger.
This suit is but one of many either known pending or already filed, alleging Assisted Living facilities of providing an inadequate level of care, inadequate levels of staffing, insufficient training for staff to care for residents with more advanced cognitive and physical conditions, and as in this case, insufficient investments in equipment and tools necessary to support staff in their care duties.
Not too coincidental, the Senate Special Committee on Aging is conducting a hearing today on staffing, resident care and safety, and pricing involving representatives from Brookdale, Atria Senior Living, and Sunrise Senior Living – the three largest Assisted Living organizations in the U.S. More here, courtesy of McKnight’s: https://www.mcknightsseniorliving.com/home/news/us-senate-launches-investigation-of-assisted-living-after-lay-media-reports-about-safety-staffing-pricing/
The impetus for the scrutiny on Assisted Living facilities is a series of news/media stories in the Washington Post (stories of deaths due to wandering) and the New York Times and Kaiser Health News regarding Assisted Living costs and pricing. In a series of posts, I covered these stories and the policy and industry ramifications.
- https://rhislop3.com/2023/12/18/washington-post-and-assisted-living-not-so-good-news/
- https://rhislop3.com/2024/01/12/friday-feature-regulatory-shake-up-20-states-revamp-assisted-living-laws-in-2022-2023/
- https://rhislop3.com/2023/04/04/litigation-risk-and-assisted-living-facilities/
Long time readers and followers of this site will recall that news stories on Assisted Living and inadequate care, staffing concerns, etc. are not new. PBS Frontline did a focused report in 2013 on Emeritus Senior Living (primarily), covering similar content and issues as recently covered by the Washington Post and the New York Times. I wrote two pieces on the PBS/Emeritus story back in 2013.
- https://rhislop3.com/2013/07/29/emerituspbs-and-a-window-on-assisted-living/
- https://rhislop3.com/2013/08/06/assisted-living-pbs-and-the-lessons-learned/
As I look back at the posts from 2013 and the PBS story and compare the same to the news current and of course, the story today, the same theme or core concern remains. Back in 2013 I called this concern basically, “appropriateness”. This is fundamentally an issue of whether a resident and his/her unique care needs, can appropriately be managed in an Assisted Living setting or, by the provider operating the Assisted Living. Not all facilities, in all states or areas, are the same, even though, a certain level of homogeneity exists via state licensing requirements. In other words, some facilities specialize and (may) have invested in tools and staff adequate to care for more cognitively or physically impaired resident while some, may not be suited to handle a more complex resident.
As providers make or break financially, based on occupancy levels, denying residency or transferring residents ill-suited to a facility’s capabilities for care, creates a risk-reward tug of war. Many executives and administrators receive incentives based on occupancy levels. Many families are often emotionally challenged by the question of their loved one’s real needs (perhaps) for a more institutionalized or structured environment. Costs may be an issue.
The issues are multi-factorial for providers and residents/families and not easily solved. I do, however, know one thing after my decades in healthcare, senior living, etc., – more regulation won’t solve the problem alone and certainly, not without all stakeholders buying into a commonsense series of definitions and controls.