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Another nursing home gets cited, a resident died after she fell down stairs, in her w/c.

LORAIN — A local nursing home was cited by the Ohio Department of Health after an 90-year-old woman fell down several stairs in her wheelchair and died, according to an Ohio Department of Health spokeswoman.
Autumn Aegis Nursing Retirement Community, 1130 Tower Blvd., was cited for failure to ensure that each resident received adequate supervision and assistance devices to prevent accidents, according to the agency’s investigation report.

Delores Gayoso, 90, got through a secured door in her wheelchair at Autumn Aegis on Oct. 8 around 9 p.m. and tumbled down several stairs. Lorain County Corner Dr. Paul Matus has said Gayoso landed in a position where she asphyxiated herself. Her death was a direct result of the fall, he said.

”It was determined that the facility failed to provide adequate supervision to prevent an elopement and failed to ensure that assertive devices (door alarms) used to prevent elopement functioned properly,” the report said.

The citation is a level ”J” because there was an immediate jeopardy, according to Michelle LoParo, spokeswoman for the Ohio Department of Health. Citations are classified A through L, with A being the least serious and L being the most.

The Ohio Department of Health conducted an investigation after the nursing home filed a facilities self-report documenting the incident. The department finished its investigation Oct. 17 and Autumn Aegis received the citation Oct. 20. The home has 10 days to respond to the complaint.

The report specified that Gayoso was severely confused and had a history of exit-seeking behavior. The resident was placed in ”immediate jeopardy when she exited an exterior door that did not alarm, fell down five concrete steps in her wheelchair and landed upside down on a concrete pad,” the report said.

Within the next 10 days, Autumn Aegis will submit a plan of action or dispute any and all of the allegations with reasons, LoParo said.

Michele Schlabach, spokeswoman for Sprenger Retirement Centers, which owns Autumn Aegis, has said the door Gayoso exited is locked with a code that is only available to staff and family members.

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