Following patient death, state bars Eugene nursing facility from admitting new residents

After a 67-year-old woman in a wheelchair with dementia was found dead after slipping away from the South Hills Rehabilitation Center in Eugene, state regulators have ordered the facility not to admit any additional patients.

The order from the state Department of Human Services said that residents of the facility are “at risk of immediate jeopardy.”

The order requires the facility to implement a plan of correction and train its staff on appropriate care for residents with dementia before the restriction can be lifted.

The order comes after resident Carol Clove Petitti slipped away from the facility July 5. She was found dead three days later, July 8, near 29th Place and Onyx Street, about four blocks from South Hills Rehabilitation Center.

Eugene police said the Lane County Medical Examiner is investigating her cause of death.

The order from the state said the July 5 “elopement” came after two similar incidents on July 3 and 4.

On July 3, the order said, Clove Petitti slipped away from the facility. On July 4, she crashed her power chair into a flowerbed, requiring the use of a lift to get her out. 

The order from the Department of Human Services states the nursing facility failed to reassess the resident’s risk of elopement after the two earlier July incidents, allowing the fatal wandering episode to occur.

Elisa Williams, a spokesperson for the Department of Human Services, said the department’s Office of Aging and People With Disabilities, known as APD, enforces these regulations on behalf of the state and at the direction of the federal Centers for Medicare and Medicaid Services.

“As soon as APD is notified of a serious incident, the nursing facility team triages the incident for response based on the information available,” Williams said in a July 16 email to Lookout Eugene-Springfield. “The team simultaneously assesses the potential for imminent risk to other residents, determines if immediate action is needed by the facility to address lapses in safety protocols, and begins its investigation of the incident.”

The facility, owned by Volare Health, has 21 days to request a hearing to challenge the order, which took effect immediately and remains in place regardless of any appeal.

Lookout called Volare Health’s corporate headquarters in Louisville, Kentucky, but the call was made after business hours in the Eastern time zone and was not immediately returned.