A Portland rest home, where a schizophrenic resident who had been missing for more than 18 hours was later found dead in the Connecticut River in 2012, is undergoing 18 months of monitoring by the state Department of Public Health and has had to hire an independent consultant to improve its practices.
Under a consent order released by DPH Tuesday, Luel Swanson, the administrator at Greystone Rest Home, also agreed to provide sufficient personnel to monitor its residents, report unusual occurrences to the state and enforce its policies on residents who don’t return from leaves.
State records show that the 59-year-old resident had a troubled history, including trying in 2011 to thrust a piece of glass down her throat and gouge her eyes out. The woman also had hallucinations and heard voices, DPH records show.
On Jan 26, 2012, the woman signed herself out to visit the local library and go to dinner and was expected to return at 6:30 p.m., records show. Records show one staff member noticed that the resident had not returned at 8 p.m. but did not tell the overnight staff that she had not returned because, the staffer said, “it totally slipped my mind.”
A staffer on the overnight shift noticed that the woman was missing but assumed she had gone on an overnight leave and did not tell anyone on the day shift, records show. A staff member noticed the woman missing at 10:30 a.m. and reported it to an administrator, records show, but the Portland police were not called until 18 hours and 45 minutes after the woman was expected to return to Greystone.
A Greystone employee then reported to police that a suicide note had been found in the resident’s room, records show. The records state that the home did not report the woman missing sooner because the staff was following its own protocol and had gone out in a car looking for her.
Swanson confirmed that the resident was Margaret Oliver. The death has been “traumatic” for Greystone residents and employees, Swanson said. “Since Margaret Oliver chose to take her own life, which was over a year ago, it has been very difficult at Greystone, but we have made many improvements in safeguarding residents,’’ she said.
The state monitoring has been positive, Swanson said, because it has led to improvements such as more headcounts of residents on each shift, a new buzzer and alarm system and closer tracking of the 58 residents at the home.
Swanson described Oliver as a “very intelligent woman” who was able to sign herself out for frequent visits to the library and hold down a job at a local health food store despite “grappling” with “severe mental illness.”
Swanson said she did not want to comment on specific statements in the DPH records, including the 18-hour missing period, because “I want to honor Margaret.” She said Greystone has operated for nearly 60 years and has won national awards for the care it provides.