Following the death of a 93-year-old woman who died after spending hours in frigid temperatures outside her nursing home Feb. 8, questions remain about staffing at the facility and an alert system that was supposed to keep her safe.
Margaret Healey, an Alzheimer’s patient and resident at Bickford Health Care Center in Windsor Locks, was outside for more than three hours before being found by staff, Windsor Locks police said. Police said Healey left the building at 1:50 a.m. and that staff have told police that they didn’t know Healey was missing from her bed until 4:45 a.m. at which time they started searching for her, first inside the building and then outside.
When they eventually found her, police said, she was unresponsive in the snow about 40 feet from the building. Staff brought a wheelchair to bring her back inside, where they used blankets and tried to bring up her body temperature, Lt Paul Cherniack of the Windsor Locks Police has said. Police were not called until 6:23 a.m., Cherniack said. EMTs on the scene pronounced Healey dead at 6:46 a.m. at the long-term care facility.
A police investigation concerning Healey’s death continues amidst concerns raised by senior advocates and family members of facility residents about an alert system designed to prevent people with dementia from leaving a facility or walking to unsafe areas. WanderGuard is the most common brand.
One family member at Bickford said, “I have personally witnessed residents who were known to wander breach secure areas and I have seen a resident wearing a WanderGuard approach a door without the alarm activity. These are serious safety failures.”
“There are caring, hardworking staff here who have taken good care of my loved one, and I am grateful to them,” the family member said. “ But frontline staff do not set policy or staffing levels. Responsibility for preventing tragedies like this lies with leadership, and there must be real accountability so this never happens again.”
The future of Bickford is also in question. The owner of the facility, Newport Bickford, owes $105,292 in taxes to the town of Windsor Locks, according to Adam Cohen, special counsel for tax enforcement.
An auction is planned for the Bickford Health Care Center property at 14 Main St. and the house next to it on April 23, according to the Connecticut Tax Sales site.
Cohen said the property owners have not appealed that determination.
Bickford Health Care Center declined to comment for this article.
WanderGuard
Healey was known to wander, as is common to Alzheimer’s patients, and was equipped with an alert device designed to set off an alarm if she left certain areas, police said. Police were working to determine whether the device failed to set off the alarm or whether staff failed to hear it.
Many facilities employ the use of alert systems like WanderGuard. Residents wear either a bracelet or ankle monitor. If they approach a door they are not supposed to enter, the doors, which have sensors, will lock and an alarm will sound. Most brands use a small device about the size of a Fitbit or Apple Watch.
It has been reported that Bickford has a WanderGuard system and the system was being used to protect Healey.
Video surveillance of Bickford showed that Healey exited the facility through an employee entrance at the rear of the building. That door is not equipped with the alert system equipment, police said, “but is designed to remain closed and locked. A keypad adjacent to this door requires a code to unlock the door. Investigators learned that this door is often left propped open, but the access code is also printed by the keypad.”
Mairead Painter, Connecticut’s long term care ombudsman, said that “If there is a WanderGuard system throughout the building then I wouldn’t expect to see a non-resident area that a resident could access.
“I would expect that the entrance to any non-resident area to either be locked or part of the WanderGuard system,” she said.
Sam Brooks, director of public policy for the National Consumer Voice for Quality Long-Term Care, a national nonprofit which advocates on behalf of consumers of long-term care settings, said “understaffing is the issue that underpins most bad outcomes in nursing homes.
“WanderGuard is something that nursing homes rely on in lieu of staffing,” he said. “WanderGuard systems can break. They also have to be monitored and there is a variety of ways they can fail especially at night. Nursing homes are perennially understaffed at night.
“I have seen it when it did not work and when it was not turned on, and was working but there was no staff to respond to it. It could be for a variety of reasons. Unfortunately this happens quite commonly,” he said. “Facilities lose residents. Residents that are at risk of elopement or leaving have WanderGuard systems but nevertheless it still occurs.”
Brooks said “when someone dies it is the failure of the nursing home.
“There should be a lot of safeguards in place to make sure this doesn’t happen to residents,” he said.
According to an article in The Iowa Capital Dispatch on Jan. 8 of last year, a “West Des Moines nursing home” faced a “wrongful death lawsuit filed by the estate of a man who wandered away from the home last October.”
The Iowa Capital Dispatch reported, that, according to the lawsuit, Richard Cox had “a history of wandering from the care facility and wore a WanderGuard bracelet designed to activate an alarm when he approached or passed through the building’s exit doors.”
Christopher Cowlan, security systems sales engineer for CertaSite, which configures and installs WanderGuard systems, said he is not “privy to any issues” with the systems.
“With any wireless technology there is that risk of interference,” he said.
Securitas Healthcare, which manufacturers WanderGuard said on a blog on its website that more than “9,000 senior living communities rely” on WanderGuard, which was developed more than 40 years ago.
“No matter how the tools change, the mission remains the same: protect residents without taking away their sense of self. Give caregivers smarter support,” said Bill McCarthy, president of Securitas Healthcare, on its blog.
Securitas Healthcare did not return emails for comment for this article.
Matt Barrett, president and CEO of the Connecticut Association of Health Care Facilities and Connecticut Center For Assisted Living, said in an email that “specifically federal regulations require all nursing homes to ensure adequate supervision of residents to prevent accidents.
“These include a requirement that facilities identify specific risks, such as residents at risk of elopement, and put measures in place to prevent such occurrences including policies and procedures to mitigate wandering or elopement risks,” Barrett said.
Barrett said that “CAHCF believes that most nursing homes use a resident electronic monitoring bracelet that signals an alarm when the wearer attempts to leave the building in addition to other measures.”
He said that CAHCF does not have specific data on the utilization of WanderGuard in the state’s 197 nursing homes. He said Bickford was not a member of the CAHCF organization.
Kristina Zdanys, UConn associate professor of psychiatry and geriatric psychiatrist, said when someone has Alzheimer’s disease or another form of dementia “they can frequently be disoriented and they don’t necessarily know where they are or what time of day it is.”
She said “they may not realize it is the middle of the night and they might try to leave where they are and try to find where they think they should be.”
Staffing
Painter said she hears ongoing complaints related to staffing at Bickford and other nursing homes in the state.
“It is important to be clear that technology and locked doors are tools, not total safeguards,” she said. “No electronic system can replace the presence of well-trained, attentive staff. Under the law, nursing homes are required to maintain sufficient staffing levels to meet the individualized needs of every resident. True safety is built on human oversight and person-centered care, not just physical barriers.”
Painter said “this is just one example of why requiring and enforcing a minimum staffing level is so critical.”
The Long Term Care Community Coalition, a nonprofit organization which tracks statistics on staffing in nursing homes, said in a release that the “overwhelming majority of U.S. nursing homes are operating with insufficient staffing to meet the basic needs of their residents.”
Rob Baril, president of SEIU 1199, a health care union representing 29,000 nurses, CNAs, direct care workers and other frontline staff across Connecticut and Rhode Island, said in an email that “while this was not a unionized facility and no members of 1199 NE were involved, the crisis of unsafe staffing is a problem across the state and until Connecticut holds nursing home owners accountable, tragedies like this will continue to happen.
“The reality is that adequate staffing does not happen without real investment,” Baril said. “Funding is desperately needed to ensure facilities can hire and retain enough workers to provide safe care. Staffing ratios today are often literally half what they were two or three decades ago, and patients, residents, and their families are paying the price.”
State Rep. Jane Garibay, Windsor Locks Democrat and House chair of the Committee on Aging, said “anecdotally she has heard from family members at the facility that there is not enough staffing.”
The Long Term Care Community Coalition’s report on federal staffing data found that “nine in 10 nursing homes fall below their expected staffing levels and the average facility is under-staffed by 25% on a daily basis.”
Bickford has a one-star overall rating from the Centers for Medicare and Medicaid services, records show. The rating is based on a nursing home’s “performance” in health inspections, staffing and quality measures. The facility had 24 health citations over the last three years compared to the national average of 9.6, according to CMS, records show. CMS fined the facility for violations.
Painter said that tragic things have happened in nursing homes, but she is unable to comment on specifics.
“Unfortunately there are situations that come up every day in nursing homes and some rise to higher levels than others but we hope that people do their best to be accountable for the care, well-being and quality of life for all residents,” she said.
Asked if she has seen in her career a situation similar to the incident in Windsor Locks, Painter said, “We don’t commonly see people who are outside a nursing home without support.”
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