Dementia Patient Dies From Hypothermia After Wandering Away From Assisted Living Facility

An elderly woman was found dead after she managed to walk away from an assisted living facility.“It's a tragedy,” said the sheriff. “It’s just a terrible, terrible thing."

The last few minutes of the 84-year-old woman's life were no doubt frightening and painful.Autopsy results show the dementia patient, who was found in a watery ditch across the street from the home, died of hypothermia.

She somehow walked away from the facility between 2 a.m. and 4 a.m. on a Tuesday.She wasn't wearing shoes or even a sweater over her nightgown. "It was about 27 degrees that evening so you could see if she did fall down in that water, how agonizing her death had to be,” said a neighbor.

Nearby residents and local police said this isn't the first time the center has been under investigation.A number of code violations may have added up to make Tuesday’s tragedy possible.Three of the six doors were not operating properly and locks were left undone.The owner of the facility is also accused of not always filling out the residents’ prescriptions, including inhalers and Vicodin. The facility had been investigated by the state at least seven times over the past few years.

The sheriff said his deputies have been called to home in the past several times for walkaways, but that this latest incident could ultimately result in a negligent homicide charge. For more, read the story.

This case is a terrible tragedy, one that never should have occurred. A dementia patient should not be able to get out of an assisted living facility in the middle of the night. The nursing home could and should have done more to prevent this tragedy.

A mobile, dependent, cognitively impaired patient should never be permitted to wander or elope undetected and unsupervised. A nursing home or assisted living facility must recognize the risk of wandering or eloping and take immediate steps to ensure the patient’s safety. Staff should be educated and warned about the patient’s risk of wandering or eloping. The nursing home or assisted living facility should also use electronic alarms that will notify staff immediately when the patient leaves the facility or a safe area in or around the facility.

Elopement occurs when a patient who lacks safety awareness leaves a nursing home or assisted living facility or a safe area within or outside the facility without the knowledge of the facility’s staff and without proper supervision. A patient who elopes is at risk of heat or cold exposure, dehydration, drowning, getting struck by a motor vehicle, and falling. Facility policies should clearly define the procedures for monitoring and managing patients at risk for elopement and otherwise minimize the risk that a patient will leave the facility or a safe area without authorization or appropriate supervision. In addition, the patient’s care plan should address the potential for elopement. A nursing home or assisted living facility’s disaster and emergency preparedness plan should include a plan to locate a missing patient who has eloped.


Robert W. Carter, Jr. is a Virginia attorney whose law practice is dedicated to protecting the rights of the victims of nursing home and assisted living neglect and abuse in Richmond, Roanoke, Norfolk, Lynchburg, Danville, Charlottesville, and across Virginia.

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