Fly on the wall 3/2/09

This week we experienced a very frightening situation, which was directly related to the  HFS process of relocating residents. HFS schedules when the residents are going to be transferred with the receiving facilities and then informs us the afternoon before.  The day of, HFS monitors the process and ensures transfer of the residents.

Yesterday, while they were monitoring the transfers, one HFS employee somehow allowed a resident to leave unnoticed. This was a 76-year-old woman, who is not allowed to leave the building without supervision due to being unsafe in the community. IDPH refers to such incidents as “elopements.”  The resident walked out the door the monitor was monitoring at about 1:30 pm and was wandering the community until the police found her outside, cold, at 4:00 am the next morning. Just to put this in perspective, this incident was more serious than any cited during the federal survey which decertified the facility.

Do they get cited? Lose their jobs? What?

Is the HSF supervisor on-site held responsible for the staff even though the employee acted independently, similarly to how administrators get cited when their employees act independently?

The reality of this situation is that good people make mistakes. No one is saying that the HFS worker wanted this to happen, is a bad person, or doesn’t know how to do her job. She is human and humans are not perfect.

Somerset was being held to the unrealistic standard of perfection during the last survey, which resulted in decertification. Substantial compliance was truly met by the facility. The Feds definition of substantial compliance was 100 % compliance. Really?? How many humans, businesses or even government agencies can meet that standard?

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