In Wisconsin, Delores Wiersum, 85, died in January after wandering outside in her pajamas. Delores’ family is suing the assisted living facility for negligence. Delores was found on Jan. 17 lying in her blood on a sidewalk. She had been wandering in 15 degree weather for four hours, and had fallen—five times—and had multiple broken bones. She died en route to the hospital.

See article at Milwaukee-Wisconsin Journal Sentinel

CBS 11 News reported that a recent state investigation of Estates Healthcare and Rehabilitation Center, a Texas nursing home, confirmed that the facility’s neglect caused a resident’s death.  On July 8th Luis Martinez, a resident went missing.  Upon hearing the news his family feared the worst since Martinez suffered from Alzheimer’s disease and relied on a cane to walk.  For 7 long days, Martinez’s wife and children anxiously searched for him until his son stumbled on the sickening sight of his own father’s decomposing body a mere four blocks from the facility.

Sadly the investigation reveled that Martinez’s tragic death was completely preventable, had the facility simply done their job.  Martinez was assessed as being high risk for elopement and often expressed to staff that he planed to leave the “prison.”   Because of this, he was placed on a special floor with added safety precautionsHowever, Martinez was removed from the floor, without assessment, due to overcrowding.  Then Martinez, a know “flight risk”, was placed alone in a new room with a door leading to outside.  Incredible!

The only steps the facility took to ensure Martinez’s safety was placing a wander-guard that would alert them should he leave the facility. Clearly, that was not enough since a wander-guard was found in the trash the night he disappeared.  The administrator of the facility showed no remorse for the incident, commenting that she initially was not worried because she though the family had taken Martinez and even admitting that she knew the wander-guard alert system was “not fool-proof.”   She even bragged that her staff did a “fine job” dealing with Martinez’s disappearance.

Even more maddening, the facility faced no consequences for their neglect and simply had to submit a plan of correction for things to return to normal. The lack of concern and remorse the facility showed and the absence of consequences in such a senseless tragedy is extremely disheartening.

St. Louis Today reported that the daughters of a resident who died after wandering away from a nursing home here filed a wrongful-death lawsuit alleging negligence.  Aubrey Giles was reported missing from the Midwest Rehab and Respiratory Center on Jan. 14. His body was found two days later in a wooded, frozen ravine nearby. Officials said he appeared to have died of hypothermia.

The family alleges that the home knew Giles had a pattern of trying to leave but failed to monitor him. It further alleges the nursing home was negligent, violated various state regulations and failed to provide adequate supervised care. The suit also alleges the nursing home "failed to timely notify local law enforcement and Aubrey Giles’ family of his elopement."

The facility is better known by its previous name, the Calvin Johnson Care Center.  This month, the incident spurred the Illinois Department of Public Health to issue eight citations against the home.


The Winston-Salem Journal reported the $20,000 fine given to Bradford Village of Kernersville, N.C. for failing to keep a blind resident safe.  The poor woman wandered away from the facility unsupervised and drowned in a puddle about 200 feet away.

The report found that the resident had approached staff in the front lobby three times between 11 p.m. and 12:30 a.m., each time in a confused, disoriented state. She asked someone to take her across the creek to the next county. Staff said they took the resident back to her bed each time, and she was in her bed at the 2 a.m. check.

The woman somehow left the facility between 2 and 4 a.m. on Nov. 12, 2009, through a door with the alarm turned off.  Employees told state investigators that the alarms were often turned off to allow workers to take smoking breaks, and the third-shift supervisor was unaware the alarm needed to be activated at 9 p.m.  The resdient was reported missing at 4:15 a.m., and a family member finally found her lying face down in water about 2 inches deep.

The home was found in violation of three codes regarding physical environment, personal care and supervision, and resident rights. The agency said the home "failed to ensure measures were utilized to prevent residents assessed as being disoriented and having wandering behaviors from exiting the facility building unsupervised."


KCBD out of Lubbock, Texas reported the investigation into the death of Willie Joe Byers who froze to death at the Tumbleweed Nursing Home. Police concluded that Byers died after being outside for several hours in freezing temperatures. He was finally found by a nursing home employee in the outdoor courtyard.  The staff is supposed to check on residents every two hours. The Texas Department of Aging and Disability requires that if a facility accepts a new resident that is reported to have dementia and/or a history of wandering, the resident should be closely monitored.

Deion Mitchell, Byer’s Nephew, said that he "found out about his Uncle’s death from a family friend, who knew someone that works at the facility. We had no idea that he was even transferred to the Tumbleweed Nursing Home."

According to Byer’s nephew, "Surveillance cameras show that Willie walked out of the facilities back courtyard door and apparently fell and hit his head while outside, and was found lying next to a shed."



The San Jose Mercury News had an interesting article about recent research into dementia. In 1980, about 2.8 million Americans were diagnosed with Alzheimer’s disease — the most common form of dementia.  But with better recognition, longer life expectancies and advanced treatment for other diseases such as cancer, that figure has nearly doubled in 2010, to 5.3 million, according to Elizabeth Edgerly, a chief program officer with the Alzheimer’s Association, a national advocacy group. In all, 42 percent of people 85 and older will get Alzheimer’s, Edgerly said.

"The ability to recognize dementia has improved over the last 20 years," said Rick Kovar, emergency services manager for the Contra Costa County Sheriff’s Office. "The science behind searching for people with Alzheimer’s has become efficient and scientific."

Dementia affects the brain in several ways. People lose short-term memory, the ability to communicate, express emotions and follow a conversation. They have severe mood shifts, and lose the ability to reason, problem-solve, sense danger and judge visual spacing.

"Wandering is one of the most common behaviors associated with dementia," Edgerly said. Sixty percent of people with dementia will wander at least once. Of those, 20 percent wander repeatedly.

The team studies "lost person behavior," which is different for various groups of people who are lost. For example, an elderly person with dementia behaves differently than a missing hiker or child.  A person with dementia may not recognize objects such as bodies of water or bushes, and walk right into them. They go until they become stuck. When they hit a barrier that blocks their way, they keep running into it until they find a way around, a phenomenon search professionals call "ping-pong." They tend to travel in as straight a line as possible.

Another well-known characteristic is patients trying to return to a place that may no longer exist.  Wanderers typically travel up to 2 miles away from their starting point, which is why the initial search perimeter starts at that distance and expands as needed.

Wanderers are more susceptible to becoming victims of crime, and because of their age they may be seriously injured in falls or made ill by poor weather.


Milwaukee-Wisconsin Journal Sentinel had an article about the horrible care and fraudulent documentation at Mount Carmel Health and Rehabilitation including 35 violations of regulations for minimum care.  "Records also show, however, that the 35 citations issued so far this year to Mount Carmel are close to the 40 citations issued in all of 2009 and more than the 25 issued in 2008, according to the state Department of Health Services."

Staff at the state’s largest nursing home recorded on charts that a 41-year-old brain-damaged resident was in his bed watching TV when he was sitting in jail. The man spent five days in custody,  Staff had continued to mark on charts that he was at the facility through the night and into the morning of May 17. 

The man wandered away from Mount Carmel and was arrested for "prowling" more than four miles away.  The nursing home was aware that he was a wandering risk and were ordered by phyisicians to check on him every 15 minutes. The other violations cited this year include failing to communicate with a recent amputee and failing to provide for five residents at risk of falling, including one who was hospitalized for a broken jaw after falling out of his wheelchair.

Licensed for 473 beds, Mount Carmel is the largest of the 397 nursing homes in Wisconsin, according to the Department of Health Services. In January 2009, Kindred Health Care, a Louisville, Ky., for-profit company resumed operation of Mount Carmel. After operating with a probationary license for one year, Kindred was given a full license in January of this year.

The citations issued this year include two identifying "actual harm" to residents and five for violations that constitute a "direct threat to health, safety and welfare," state records show.

Other citations
Among other things, Mount Carmel was accused of:

• Failing to provide appropriate supervision and assistive devices to five out of 10 residents identified by Mount Carmel as being at risk for falls.

Three of the five had fallen since last December, including one who suffered a broken jaw and an eye socket "blowout." A hospital that treated the woman reported the incident to the state but Mount Carmel, which was required to report the incident, did not.

• Failing to assess and treat pain, depression and other problems experienced by a 51-year-old woman.

• Sixteen of 32 residents reviewed were not treated "in a manner that maintained their dignity."

Two were kept in a small alcove near an exit; at least six were kept in an old nursing station or in a hallway for extended periods; and an incontinent resident said staff turned off his call light four times after he sounded it and had a bowel movement before any staff took him to the toilet.

The September inspection also found that after a resident complained of hip pain, Mount Carmel did not notify a physician for two hours and 15 minutes. The doctor ordered an X-ray, but the order was not relayed by a nurse for 2 1/2 hours. The X-ray revealed a broken hip.

The article had a Summary of violations Mount Carmel Health and Rehabilitation Center in Greenfield was cited for 35 state and federal violations so far this year. Among them:

March 2010: A 51-year-old resident who had her right leg amputated below the knee in December 2009 did not have staples removed as of March and no adequate assessment or treatment of the resident’s "phantom pain" in the leg had been done.

Mount Carmel also was cited for failing to communicate with the resident, who did not speak English, in Spanish. Among other things, staff was not aware that the resident experienced phantom pain and that she had been dropped by staff. A registered nurse told an investigator she didn’t need a Spanish interpreter because relied on documents and the resident’s gestures and facial expressions.

Also in March, an investigator found that 16 of 32 residents reviewed were not treated "in a manner that maintained their dignity." Two had been transported in shower chairs with bare legs or buttocks exposed; two were kept in a small alcove near an exit; at least six were kept in an old nursing station or in a hallway for extended periods; an incontinent resident said staff turned off his call light four times after he sounded it and had a bowel movement before any staff took him to the toilet.

January 2010: A federal investigator finds that, going back to December, five out of 10 residents identified by Mount Carmel as being at risk for falls did not receive appropriate supervision and assistive devices, and that three of them fell. A 92-year-old resident who needed supervision was dropped off at a medical appointment by herself. .

Dec. 3, 2009: A resident who lacks the ability to move in bed, is found on the floor next to her bed. She suffers a broken jaw and an eye socket "blowout," according to a federal investigator. The hospital reported the injuries to the state Office of Caregiver Quality, but Mount Carmel, which is required to make a report, did not. When the investigator asked a Mount Carmel administrator on Jan. 11, five weeks after the incident, whether Mount Carmel had reported the incident to the state, the administrator said no report had been made because Mount Carmel "felt they knew how the incident occurred."

Nov. 5, 2009: Resident suffers laceration to left palm requiring sutures in a hospital emergency room. Hospital reports the injury to the state, but Mount Carmel did not. Mount Carmel could not determine how the incident occurred.


MYFox9 had an article about the Minnesota Department of Health’s investigation into the wandering death of a resident who froze to death.  The investigation revealed that the Jones-Harrison assisted living facility was guilty of neglect in the death of a patient who wandered outside last November.  The cause of the patient’s death was listed as hypothermia from cold exposure.

Staff carelessly lost track of the woman with dementia on the evening of Nov. 21.  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. 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 concluded that the resident walked through a gate door that was left open.  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.  There was no explanation why another staff member did not see that the gate was unlocked or how the resident was able to leave the facility without anyone noticing.

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.


NY Times had an interesting article about wandering among residents with dementia.  Many people with dementia do not fit the textbook definition of wandering, "To move about without a definite destination or purpose."  It is a serious problem in long term care facilities.  The article discusses the public safety concerns and the sad case of Freda Machett.

"Ms. Machett, 60, suffers from a form of dementia that attacks the brain like Alzheimer’s disease and imposes on many of its victims a restless urge to head out the door. Their journeys, shrouded in a fog of confusion and fragmented memory, are often dangerous and not infrequently fatal. About 6 in 10 dementia victims will wander at least once, health care statistics show, and the numbers are growing worldwide, fueled primarily by Alzheimer’s disease, which has no cure and affects about half of all people over 85."

“It started with five words — ‘I want to go home’ — even though this is her home,” said Ms. Machett’s husband, John, a retired engineer who now cares for his wife full time near Richmond. She has gone off dozens of times in the four years since receiving her diagnosis, three times requiring a police search. “It’s a cruel disease,” he said.

Searching for them often also means learning a patient’s life story as well, including what sort of work they did, where they went to school and whether they fought in war. Because Alzheimer’s disease, the leading cause of dementia, works backward, destroying the most recent memories first, wanderers are often traveling in time as well as space.

Advanced age can compound health risks of exposure.   Nursing homes should have a locked unit, enough staff to supervise, and alarms on all residents with dementia,

The St. Clair Record had a story about Jewel Lane.  Jewel Lane was living at Maryville Manor when they allowed him to fall and then later allowed him to leave the premises unattended.   Jewel Lane died on April 7 because of exposure to the elements, pulmonary arrest and hypothermia. 
His wife and daughter have filed suit against the nursing home which allowed the man to escape, leading to his death.

The surviving Lanes blame the nursing home for causing their father’s and husband’s death, saying employees there failed to properly supervise Jewel Lane to prevent him from leaving the nursing home, failed to provide adequate staff to prevent him from leaving the nursing home unattended, failed to protect him from neglect, failed to timely notify his physician of changes in his condition and failed to assure his environment was free of hazards.

In addition, staff at Maryville Manor negligently failed to provide adquate warnings to the proper personnel to quickly locate Jewel Lane; failed to properly secure exits, including windows, so that patients could not escape unnoticed; failed to provide Jewel Lane adequate care so he would not harm himself; and failed to house Jewel Lane in a room that would prevent him from exiting the premises, the complaint says., an ABC news website for Albuquerque, ran an article about Roland Werito who had been missing since he left the Paloma Blanca Nursing Home.  Police said the nursing home allowed Werito to leave the facility unattended towards the bike path in his wheelchair just blocks from the nursing home, but his wheel rolled off the path, down the hill and his chair got stuck. No one found him until it was too late.

When Werito didn’t show up by 9 p.m., staff members at Paloma Blanca got worried. They called police and Werito’s family. Police said someone saw Werito from a nearby Motel 6 and called 911.

Werito died of hypothermia.

DailyComet ran an article about another wandering incident.