Staff at Autumn View Gardens assisted living facility in Creve Coeur put residents in imminent danger in January when three residents with dementia were found outside the building in freezing temperatures, according to a state investigation.
The facility, owned by Colorado-based Bethesda Senior Living Communities, satisfied investigators’ citations by installing a new door alarm system, retraining staff on supervision policies and adding a full-time receptionist at the front desk.
Joshua Thomas, Bethesda’s regional vice president of operations, said he couldn’t comment on the residents’ situations but provided a statement.
“We are a mission-driven, nonprofit organization and we take the safety and security of our residents very seriously and review our safety protocols periodically. We take great pride in the care that we provide to all of our residents.”
One resident with Alzheimer’s disease went outside without a coat for 10 minutes on Jan. 3 when the temperature was 27 degrees. The next day, the resident again went outside without a coat or shoes when the temperature was 18 degrees. On Jan. 6, with a temperature of 4 degrees, the resident went outside a third time without coat or shoes. Family members had previously expressed concern about the resident’s tendency to wander, inspectors from the Missouri Department of Health and Senior Services wrote in a February report after a visit to the facility.
During the inspectors’ visit, there was no documentation of the resident as an “elopement risk” and no picture posted at the front desk as recommended. The resident’s doctor told the inspectors that the resident had worsening dementia and should not be allowed to go outside unsupervised.
A second resident with dementia was found sitting on the ground two blocks from the facility on Jan. 24 with no coat and wet pants in 42-degree weather. A passer-by had alerted staff at the facility of “an older person walking down the street.”
A pastor at St. Richard’s Catholic Church across Schuetz Road from the facility brought back a third resident with known confusion and memory problems who had walked into the church without a coat on Dec. 30, when the high temperature was 25 degrees.
Staff members told the investigators that the front doors were locked at night but that residents could still get outside. They need to ring a bell to get back in, but “if a resident got confused and did not understand how to ring the bell or if staff were busy assisting another resident, he/she could be outside for a long time,” the report states.
When opened, the facility’s front door and side exit doors send alarms to staff members’ pagers, “but staff did not always have time to check the doors if they were busy assisting other residents,” according to the investigators’ interviews.
Autumn View Gardens’ business manager told investigators on Feb. 1 that she sat at the front desk during the day and “tried to watch all the residents and make sure they get signed out, but sometimes they would get by her.”
On Feb. 2, investigators found no one sitting at the front desk at 9 a.m. and watched a resident walk outside without signing out. Staff did not respond to the resident or to several other instances when investigators opened various doors in the facility, according to the report.
An aide told investigators that he or she had brought concerns to management about the lack of supervision of residents. There were 72 people living in the facility at the time of the investigation.
“They are supposed to be assisted living, but cannot check on everyone, assist with activities of daily living, pass medications and supervise residents when there are only two or three of them on duty,” the aide said in an interview with investigators.
The facility’s correction plan said staff members were instructed to drop whatever they were doing and immediately respond to every open-door alert.