Buffalo nursing home fined $20,580 after resident wanders off unnoticed

Feb. 6--A nursing home owned by Erie County Medical Center was fined $20,580 by the federal government after a cognitively impaired resident with a history of wandering went missing for 100 minutes last year.

The day before the Terrace View Long Term Care Facility resident wandered off, a maintenance worker there discovered an alarm on a stairway door on the resident's ward was not functioning, according to a state Health Department inspection report. The maintenance staff did not alert the nursing staff that the door was broken, however.

A video recording reviewed by state investigators showed the unidentified female resident pushed her wheelchair through the second-floor stairwell door at 6:02 a.m.May 25, according to the report. A registered nurse discovered the woman was not in her bed at 7:30 a.m. Twelve minutes later, the staff found the woman confused but uninjured, sitting on the floor at the bottom of the stairwell.

A certified nurse assistant said in a written report that she had checked on the woman at 6:40 a.m. that morning and she was in her bed, though the video suggested that could not be true, the Health Department noted.

The state cited Terrace View for failing to respond appropriately to an alleged violation because it had not thoroughly investigated why the woman was able to wander off her ward. It also cited Terrace View for failing to ensure there was adequate supervision of residents to prevent accidents.

The door was repaired by the maintenance staff May 28, according to the Health Department report. On June 6, the woman was transferred to a more secure memory care unit at Terrace View, which is located at 462 Grider St.

Erie County Medical Center, a public benefit corporation, owns Terrace View, a 390-bed nursing home that opened in 2013.

"The safety and care of our residents at Terrace View is of utmost importance and we took this incident very seriously," said Peter Cutler, vice president of communications at ECMC. "Much of the corrective actions, including retraining and action plans for employees, were taken before the Health Department arrived for their review."

The $20,580 penalty was issued Aug. 27 but did not become public until January, according to records of the federal Centers for Medicare and Medicaid Services. It is the third-largest federal fine on a Buffalo area nursing home in the past three years.

In July, Terrace View earned its first five-star -- or "much above average" -- rating from the federal Centers for Medicare and Medicaid Services. The nursing home's rating dropped sharply in January to two stars, or "below average."

Cutler said the Terrace View staff is working diligently to get the overall rating back to five stars.

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