July 25, 2018 05:27 PM
The Minnesota Department of Health has found a Minneapolis assisted living facility was negligent when a 76-year-old woman wandered out of its doors in March and was found more than eight hours later in a snow bank.
She died of complications of hypothermia in the hospital. The police and MDH reports have redacted her name.
The health department’s report was published this week and used surveillance video to determine the woman left the residence at 2:39 p.m. after two staff members forgot to latch and lock two separate doors.
The video showed the woman left the facility without “proper attire” and without her cane or walker. Investigators say it took staff nearly an hour to discover she had left, which was realized at 3:30 p.m.
The report states staff drove around the neighborhood searching for her. When the executive director was filled in at 4:30, the director told the nurse they should wait to call 911 as staff was still searching for the client, the report details.
It took the facility nearly three hours to call 911 and file a missing person report, MDH’s report details. The nurse called at 5:40 p.m.
The woman's family was then notified and joined the search, the report states.
The police report notes the woman “suffered from multiple mental and physical disabilities,” and it said officers’ search of the area was unsuccessful.
The family actually found the woman in a snowbank at 11 p.m., more than eight hours after she went missing, MDH reports.
She died from complications of hypothermia in the hospital, according to the investigative findings.
The MDH report quotes a police report stating, “The area where (the woman) was found was treacherous because there were large snow banks surrounding her. (The woman) was lying in between the train tracks and snow banks. There was little to no lighting in the area she was found. (She) would not have been visible from any roadways.”
The woman had been in the facility for six days prior to her disappearance, and investigators learned she arrived without a care plan and missing health or medical paperwork. However, four days after her arrival, the facility learned she was on medications and had dementia, the report states.
She had chronic obstructive pulmonary disease and dementia, and the woman required a cane or walker to help her move, investigators learned.
Family reportedly told the facility the woman did not take any medications and said she did not speak English well. The facility would later hire an aide who knew Korean to assist her.
Care workers told investigators the woman talked about going to the bank and repeatedly said she did not want to be there; her son was coming to visit.
A nurse told investigators she “was not given the opportunity to make a nursing assessment prior to (the woman’s) admission,” which is part of the facility’s policy. The facility does not have a memory care unit, and does not normally accept patients with a history of wandering.
The nurse said she felt there were other admissions that were not appropriate, but mentioned the director doesn’t want her to have veto power because it would prevent them from filling beds, the report states.
An investigator noted when he or she visited the facility on March 16, the front door was unlocked.
“This investigator was able to egress; walk around the building, and enter through the side door. (The investigator) was not greeted by staff,” the report states, noting the investigator let the door fall closed and observed it did not latch.
The investigator also noted that the door was locked about 20 minutes later.
KSTP has reached out to Golden Nest for a comment and has not yet heard back.
Updated: July 25, 2018 05:27 PM
Created: July 25, 2018 05:06 PM
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