By Healthcare Facilities Today

Canterbury Gardens Alzheimer Care in Longview, Wash. lost it's license to operate after a patient froze to death in it's courtyard wearing only a nightgown in the 30-degree night air.

According to the Washington State Department of Social and Health Service’s (DSHS) Statement of Deficiencies, issued to Canterbury Gardens on December 17, 2013,  the problems leading to this patient’s death were several. However, chief among them was the lack of security measures that could have prevented the patient’s exit, as well as a secondary system for alerting staff should such an exit have happened regardless, according to an article on the FacilityCare website.

An inspection by DSHS revealed that all but one door had an alarm attached; the door the patient had used to enter the courtyard was one of those without an alarm. In fact, the investigation found that none of the alarms on the three doors leading to the courtyard were permanently attached. None of those doors could be locked, since reportedly no one had a key.

“An alarm on the door to the courtyard from the dining room … was not very loud and staff reported the battery was low,” the statement said. “Staff B said she had seen an order sheet indicating maintenance of the alarms would be done ‘tomorrow.’ The alarms on all doors to the courtyard consisted of a chime, which rang only once.”

Marilyn Hollier, president of the International Association for Healthcare Security and Safety sees this tragedy as a part of the longer history of long-term care facilities’ struggle for bigger budgets, according to the article. Still, safety is among the chief responsibilities of a long-term care facility, and a number of processes and policies should be in place to keep residents from harm.

“Minimally, long-term care facilities really need to have access control practice and policies in place, by using security systems, which means that all access is controlled and monitored at all of your entrance points and exits. That would mean audible alarms, door contacts and cameras,” Hollier said. “Then if somebody went out a door it would make an audible alarm, but it would also alarm at a monitor that staff would be watching so they could see if somebody went out that door.”

Hollier said that even small facilities with limited budgets should ensure that at least one individual take ownership of the facility’s security systems to make sure they are working properly.

“The best approach, of course, is to have a security department or at least someone who wears a security hat. If it’s a small facility it may be the head of the facility manager who oversees maintenance of security, but someone needs to be accountable to make sure those systems are working the way they’re supposed to work,” she said in the article.

Read the article.