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Neglect and failure to supervise leads to wanderer’s death

Published on June 9th, 2009

The Buffalo News had a story about 3 nursing home employees who were only disciplined when the employees did not check on a resident or failed to report him missing for over 11 hours.  The Health Department found that the employees, over an 11-hour period, each noticed that Trent Lockridge was not in his room but did not report it.  The resident either fell, was pushed, or jumped from his second-floor room in Dosberg Manor on the night of Feb. 17, but his body was not found until the next morning.

The Health Department required that the facility discipline the employees involved, put in place new policies for ensuring the whereabouts of all residents and train its employees in the new system.

Health Department investigators visited Dosberg Manor after Lockridge’s death, interviewing staff members and reviewing facility records. Their report found that the first employee had responded to a Feb. 17 call from Lockridge’s roommate requesting help in closing the window. The employee noted that the window was wide open, Lockridge’s glasses were on the nightstand, and his walker was near the window. She neither investigated the fact that he was not in the room nor told anyone about it.  In fact, when first questioned by department investigators, she lied and told them that she had seen Lockridge in his room at 9:40 p.m. She later confessed to a co-worker that this was not the case, the report states.

The second employee, who went into the room at 11 p. m. as part of a daily census of residents, assumed that Lockridge had been hospitalized but did not follow up on this or attempt to confirm it.

The third employee, who was assigned to Lockridge’s floor, stopped by the room at midnight as part of her rounds and also noticed that Lockridge was not in his bed, according to the report. Further, Lockridge’s medical records reflected that staff had helped him take a dose of medicine at 6:30 a. m. Feb. 18, when he was still missing. He was not reported missing until 6:45 a. m., when a nurse said she couldn’t find him. His body had been outside for at least 11 hours in freezing temperatures.

The report concludes that the employees should have notified a supervisor when they saw that Lockridge was missing and that the window was open. It does not name them.  Neither the Weinberg Campus nor the Health Department would say what disciplinary action was taken. Weinberg has agreed to put in place a new system for keeping track of Dosberg Manor residents and to train employees in the new procedures.

 

Joe Pioletti
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