USA today reported that Phyllis Campbell, a nursing home resident with dementia and a history of wandering off, was outside in temperatures hovering around zero for about eight hours before staff members noticed she was missing and found her dead from hypothermia, a state investigation found.

The state’s findings say Campbell had wandered into the courtyard twice during the week before she died and that she got out of her room several times that day and said, “I’m going home.”

The woman told a nurse’s aide she was going home.  She went through a door into a courtyard even though she was wearing a monitor that should have set off alarms, the report said.  Tests later showed the sensors did not always work, the state’s report said. Staff members also told investigators the device didn’t always work.

Two aides told investigators they did not do scheduled checks that night even though they were marked as completed, according to the Ohio Department of Health investigation.  She was found in the courtyard about 30 feet from its doors the morning of Jan. 7.

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