Minneapolis Nursing Home Guilty of Neglect in Patient's Freezing Death

MINNEAPOLIS - A Minnesota Department of Health investigation has found a Minneapolis nursing home guilty of neglect in the death of a patient who wandered outside last November.

According to the report, staff at the Jones-Harrison assisted living residence lost track of a woman with dementia on the evening of Nov. 21, assuming she was home with a family member. Staff members were unable to locate the woman and were confused about her whereabouts before finding her around 10:30 a.m. the next morning frozen, with no pulse, near a parking garage.

The report indicated a cyclone gate door was open, leading a wooded area the patient had walked through. The cause of the patient's death was listed as hypothermia from cold exposure.

Health department investigators learned a maintenance worker leaving around 4 p.m. the day of the incident left the gate unlocked. The worker admitted to leaving it unlocked for his own convenience, using it to get to quickly get to his car in the cold weather.

The worker, who had been suspended before, was fired for misconduct and dishonesty. He had lied initially when explaining how he left the facility on Nov. 21.

A family member had in fact signed the woman out of the facility a day earlier, but returned her returned her to the facility and forgot to sign the patient back in. The family member said when she arrived at Jones-Harrison on the morning of Nov. 22, police had still not been called and the patient hadn't been seen inside the facility in 16 hours.

The health department report concluded both the nursing home and maintenance employee are guilty of negligence in the death. The nursing home did not effectively manage its resident register to keep tabs on patients, and staff did not initiate the missing persons protocol in a timely manner.

Since the incident, Jones-Harrison has created a new procedure for keeping logs of patient outings and modified its policy to require immediate notification in the case of confusion of a patient's whereabouts.