Florida retirement home may lose license following woman’s death

Employee watched resident leave, didn’t intervene, report says

Generic people in a nursing home (WSLS 10)

LAUDERHILL, Fla. – The Florida Agency for Health Care Administration has begun a process to revoke a South Florida assisted living home’s license after a 69-year-old woman who went missing ended up dead in a car in the parking lot.

Yvanne Moise left Victoria’s Retirement home in Lauderhill on Sept. 18 and never returned, the South Florida Sun Sentinel reported.

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The state health care agency's recent inspection said the facility lacked a plan required by state law to address Moise’s “severe or persistent mental condition.” And it did not have updated versions of those plans for seven of its 18 other residents who were also considered “limited mental health residents,” the newspaper reported.

Moise didn't sign out when she left the home on Sept. 18. The report said she repeatedly told a staff member she was going to leave, and by 8:30 that morning, she was nowhere to be found.

The report said an employee watched her walk out the front gate and into the parking lot. Moise didn't listen to the employee's multiple attempts to get her to stay.

The employee then went inside to to call the facility's administrator to report that Moise wouldn't come back inside.

The employee told investigators that she didn't attempt to intervene or redirect Moise.

Moise was reported missing later that day.

Four days later a mechanic found her body after noticing a foul odor coming from a SUV in the parking lot. Authorities said she had gotten into the car and died.

According to the inspection report, the facility violated a section of Florida law that requires it to notify a licensed physician “when a resident exhibits signs of dementia or cognitive impairment or has a change of condition” within 30 days after a staff member notices any signs from the resident.

If an underlying condition is found, the facility is required to arrange necessary services for the resident with a health care provider, the newspaper reported.

The report found the facility “failed to provide appropriate personal supervision of care” to Moise.

The facility administrator told the health care agency's inspectors that Moise needed to be watched and should not have been left alone outside because she had been recently hospitalized and had a “change in condition.”

She was admitted to the home as a limited mental health resident, and she was diagnosed with a mental health condition.

Her case manager and physician told inspectors that Moise did not show any signs that she was at risk of leaving when they last saw her, according to the report.

In Florida, assisted living facilities with one or more mental health residents are required to have a copy of a community living support plan and a cooperative agreement with a mental health care services provider for each resident. The plan is supposed to be completed within 30 days of the resident's admission to the home.

Moise lived there for two years, and no plan had been put in place for her mental health condition, making it “difficult to ascertain the resident’s care and service needs,” the administrator told inspectors.

The facility's owner did not respond to requests for comment. And Moise's daughter did not return the newspaper's call.

The home can appeal the health agency’s action to revoke the license, and continue providing service “until a Final Order is issued,” the agency told the newspaper.