Resident Found in Backyard After 29 Hours
Minnesota Assisted Living Resident Elopement Death at Fortunate Homes. The Minnesota Department of Health investigated an allegation of maltreatment, in accordance with the Minnesota Reporting of Maltreatment of Vulnerable Adults Act, Minn. Stat. 626.557, and to evaluate compliance with applicable licensing standards for the provider type.
According to the report, the facility neglected the resident when facility staff failed to respond promptly when the resident left the facility alone for a walk and did not return. The resident was found dead 29 hours later in the facility’s backyard.
The Facility Failed to Follow Protocol for Missing Residents
The Minnesota Department of Health determined neglect was substantiated.
The Minnesota Department of Health determined neglect was substantiated. The facility was responsible for the maltreatment. The resident had a history of elopement and poor safety judgment. When the resident had an improvement in his health, was physically able to leave the facility and wanted to walk outside multiple times daily, the facility failed to follow the resident’s required supervision while outside as care planned by the facility and case manager. The facility continued to allow the resident to walk outside, away from the facility unattended. Additionally, the facility did not follow its protocol for handling missing residents, resulting in a delay that left the resident missing for over 29 hours in the backyard.
The investigator conducted interviews with facility staff, including administrative, nursing, and unlicensed staff. The investigator contacted the medical examiner, county case managers, an outside home care agency, and multiple family members. The investigation included a review of the resident facility record and related facility policies, clinic and hospital records, county social service records, and skilled home care records. The investigator reviewed the full investigation by the medical examiner and the police department. The investigator also observed the neighborhood, including the facility’s front and backyard, as well as the area the resident frequently walked.
The resident lived in a 4-bedroom assisted living facility in a residential area with a small front yard and a backyard, mostly enclosed by a chain-link fence. The resident’s diagnoses included a traumatic brain injury, neurocognitive disorder with agitation, major depressive disorder, and a history of alcohol use disorder. The resident’s service plan included 24/7 supervision, medication administration, behavioral support, and meals. The facility’s assessment noted the resident required extensive support, especially in mental health management.
According to the report, the following day, around 12:15 p.m., a facility report indicated family members asked what the resident was wearing when he left the facility, as they would include the details in a social media missing person post. Facility management did not review video surveillance until the family inquired. Two hours later, after viewing the footage, management contacted the family to report what the resident was wearing when he was last seen 24 hours earlier. Management indicated after reviewing surveillance footage, it was unclear whether the resident ever left the backyard after he went missing. At 7:15 p.m., management searched the backyard, found the resident lying in the grass unresponsive, and called 911. A police report indicated officers were dispatched at 7:32 p.m. for an unconscious resident. Officers found the resident was lying in the backyard next to a chain link fence with no signs of life. The resident’s body was very cold to the touch and appeared stiff as if rigor mortis had set in (a process that occurs within hours after death when small muscles stiffen and around 12 hours when the entire body stiffens). The autopsy and medical examiner’s final report indicated the resident’s cause of death was an accidental drug overdose; however, hypothermia could not be ruled out. As police continued their investigation, a report indicated they reviewed facility video and saw no sign of the resident leaving the backyard or staff checking the area. Police believed the resident likely went behind the unattached garage, out of the camera’s view, and collapsed there. He was not found until 29 hours later. The last confirmed sighting was at 2:15 p.m. the previous day
For more of the report see MDH re: Fortunate House in Brooklyn Center.
In conclusion, the Minnesota Department of Health determined neglect was substantiated.
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If you have questions or concerns about nursing home injuries and accident, from wandering, elopement, including those which lead to a wrongful death suffered by someone you love contact Attorney Kenneth LaBore for a Free Consultation at 612-743-9048.