San Jose Mercury News had an article about a nursing home resident who was able to walk out of a nursing home.  Rosemary Nelson  was reported missing from a Concord nursing home over the weekend has been found dead.   Concord police say 63-year-old Nelson was found in a small culvert around 8 a.m. Nelson was reported missing Saturday night from a skilled nursing facility about three miles away from where her body was found.

Though officers had searched the area, police say Nelson’s body was discovered in an area that was difficult to see from a nearby road. The coroner’s office says Nelson died from exposure.



Philadelphia Daily News had an article about the sad death of Harold Chapman, a vet who was allowed to wander away from Delaware Valley Veterans Home.   Chapman, diagnosed with dementia and work-related brain damage, wore only pajamas when he stepped past a manned security desk at 5:30 p.m. Dec. 31, 2007, and into the winter cold. Two hours later, a staffer reported that she could not find Chapman, a Korean War veteran, in his room or anywhere else.  Ten hours passed before Chapman’s lifeless body was found a few yards from the state-run nursing home.  Details about Chapman’s death emerged in a lawsuit his daughters filed against the state.  Evidence produced for the lawsuit includes surveillance tapes of the former policeman leaving the home.

Records from the Delaware Valley Veterans Home show that there were multiple failures by staffers, first by not monitoring Chapman’s movements and, after he was belatedly discovered missing, by failing to immediately follow established emergency procedures. Staffers didn’t notify the home’s commander until after 9 p.m., more than three hours after Chapman disappeared. They didn’t call police until 9:15 p.m.

Surveillance tapes show that Chapman left his restricted area by riding the elevator with an employee who was not authorized to be in the building at that time. One staffer, one of the last to be seen with Chapman, abruptly quit his job when told he would be questioned. Called "a person of interest" by investigators, the aide later was discovered to have a criminal record for stalking.

"If he were any closer, they would have tripped over him," his widow, Barbara Chapman, said in a recent interview.  "It was New Year’s Eve, and everyone was getting ready for a party. He walked right by them," said Barbara Chapman, who viewed the tape. "He couldn’t find his way back, and got lost. They told me it was painless, but I later found out it can be a very horrible death."

The Pittsburgh Tribune-Review has been investigating state veterans’ homes and has found serious deficiencies at two of them, in Hollidaysburg and Scranton. The U.S. Department of Health and Human Services rated those facilities below average in meeting inspection requirements, giving them the lowest possible ranking: one star out of five, while other homes in the system fared better.

The 1,632-bed state veterans health system, dating to the Civil War era, costs $165 million a year to operate. It is separate from the federal Veterans Affairs. The state facilities include nursing-home beds, personal care facilities and locked dementia units, where many of the serious violations occurred.


Houmatoday had an article about the tragic incident involving Etienne Adams, a 93-year-old nursing home resident.  His solo walk outdoors on a freezing night is the subject of a police investigation.  Luckily, the resident is in stable condition at Thibodaux Regional Medical Center after recovering from a fall outside Lafourche Home for the Aged and Infirm.  He is being treated for extended exposure to freezing temperatures. He was unconscious when police found him, and he has been unable to communicate since. Hypothermia had begun to set in.  His temperature dropped to around 83 degrees, while being exposed to outdoor temperatures in the high teens

Police investigators are trying to determine how Adams made it outside without any of the staff noticing and then stayed there without anyone noticing for hours. Officials are not certain how long he was outside of the home.

The nursing home has working security features available that include surveillance cameras, door alarms and a locked fence around the building.  Obviously either the security was not on or it was ignored by the staff.  There is also no video surveillance footage of Adams leaving his room. The nursing home’s cameras capture only what it is happening in real time but do not record.

Adams left the facility and fell off of a ramp outside the facility.  There is no record of nursing-home employees looking for Adams outside once they realized he was not in his room.  After being dispatched to the nursing home on a missing-persons complaint, police found Adams on the ground near the back of the property.  Officer David Melancon’s report said “it was apparent that he had been lying on the ground for several hours.

 Here is a follow up article from the DailyComet on the investigation. 

Read More → wrote a brief summary of the verdict in a recent nursing home trial.  The family of a woman, Tong Ashby,  who survived a two-story fall out of an Evansville nursing home window has been compensated.  The accident happened six years ago at Golden Living Center Woodbridge.

At the time, Mrs. Ashby was only 57 years old and a cognitively impaired woman.  She tried to leave the home to be with her family.  While doors and elevators were kept locked at the facility, the windows in her room were kept open.  She says one day a staff member left Ashby alone and she climbed out the window falling thirty feet.   She had a history of wandering and trying to go home.  Ashby survived the fall and now lives with her son in Lexington, Kentucky. The verdict awarded her more than $250,000.

Chicago CBS had an article about the guilty plea and sentencing of a nurse that willfully neglected a resdient causing her death.  Heidi Leon entered a plea of guilty to one count of criminal neglect of a long-term care facility resident and one count of obstruction of justice. Judge Peter Dockery sentenced Leon, a Certified Nurse’s Assistant, to 180 days in the DuPage County Jail.

On February 5, at approximately 2 a.m., 89-year-old Sarah Wentworth, who had lived at the Arbor of Itasca nursing home for approximately three years, triggered an outside door alarm as she exited the nursing home. Upon hearing the alarm however, Leon turned off the alarm and continued watching television. Several hours later, Wentworth was found outside the facility and brought inside. Later that morning Wentworth passed away from exposure to extreme cold for an extended period of time.   Leon had also furnished false information to the Itasca Police Dept. in an attempt to derail their investigation.

"Heidi Leon’s failure to perform her duties cost Sarah Wentworth her life," DuPage County State’s Attorney Joe Birkett said. "Ms. Leon’s sole responsibility that night was to ensure that the residents at the facility were comfortable and cared for, not dying out in the cold."


The Cherokeean Herald had an article about the tragic and preventable death of a nursing home resident and the nursing home’s attempt to cover it up.   Police and state Attorney General’s office are investigating a death at Hillside Plaza Nursing Home.  At approximately 6 a.m., Edna May Sides was found dead outside the nursing home by staff members.

Nursing home staff contacted her family at approximately 10 a.m. the same day.  "Her family ended up notifying us," said Wells Police Chief Barry Starnes. "The nursing home treated it like a patient passing away and notified the family.  "The family thought it was a little strange, so they went to the Justice of the Peace in Alto and then called the Sheriff’s Office and our department."

Chief Starnes says "I believe there was possible negligence, but I don’t believe someone purposely did this."  "We’re trying to get to the bottom of how this person got outside when she wasn’t supposed to be," he said. "Hopefully, we’re close to coming to a conclusion."

Edna Mae Sides’ body was found in front of the Hillside Plaza Nursing Home by staff around 6 a.m.   Hillside Plaza Nursing Home staff found the body of Edna Mae Sides at 6 a.m. but for some reason did not call police for four hours at 10:15 a.m.   The time gap between when Sides’ body was found by nursing home staff, and the time it took staff to call police, triggered an "intense investigation".

"The question always arises, cops are suspicious people, why did it take you four hours to call the police?" said Barry Starnes, Wells Chief of Police.   "The time difference and then finding a body outside one of the residence and bringing it back inside and cleaning it up and all this, to police is very suspicious," said Starnes. "To people who run nursing homes, that’s standard practice."

Evidence suggests that the nursing home failed to supervise the demented resident and she wandered outside and apparently fell outside the nursing home.  Hopefully, the police will ask the right questions:  What was the staffing ratio?  Was the door alarm on?  Was it working? Did anyone respond to it?  Was a bed check done?  When was the last time she was seen?

Starnes said there are still several unanswered questions in this case. "Now, how she got out there, what procedures were not followed or what other things may be wrong, that’s all still under investigation," he said.   "She fell on her face," said Starnes. He said she was unable to get up after the fall.

The Daily Hearld had an article recently about a CNA who may get less prison time because of some stupid technicality.   The nurse’s assistant will faces considerably less time in prison if convicted of failing to provide proper care to an Itasca nursing home resident who died after wandering outside last winter into the cold.  Prosecutors agreed to drop half of the eight felony counts against CNA Heidi Leon, based on a perfunctory technicality with the wording of the state law regarding licensed nursing homes.  Leon faces five years – instead of 14 – if convicted of the remaining elderly neglect and obstructing justice charges.

Leon pleaded not guilty but has remained in the DuPage County jail on a $99,999 bond since her March 4 arrest. She must post 10 percent to be set free.  Leon is accused of failing to check in on 89-year-old Sarah Wentworth early Feb. 5 after an alarm alerted staff at The Arbor of Itasca that an outside door had opened.  Leon turned off the alarm and went back to watching back-to-back episodes of "Dog the Bounty Hunter."   She also is charged with lying to police when they said she told them she saw Wentworth in her bed during a 3 a.m. well-being check.

Wentworth was wearing an electronic ankle bracelet because she suffered from dementia and was prone to wandering. The staff found her body several hours later in the outside courtyard in near-freezing temperatures.  Judge Dockery granted Leon’s lawyers and their investigators the authority to tour The Arbor so they could photograph, measure and otherwise document the nurse’s station, television area, Wentworth’s room and the hallway she traveled that leads to the outdoor courtyard. The Arbor fought the move, despite having earlier allowed civil attorneys for Wentworth’s daughters to similarly document the facility.


Serita Cheryl Evans has filed a nursing home wrongful death lawsuit against a North Carolina facility, Primrose Retirement Villa IV,  that allowed her mother to wander out at night disoriented, fall into a ravine and die from a head injury.  The lawsuit was filed following the death of Carrie “Christine” Evans, whose body was found behind the facility on February 2.

Wandering from a long-term care facility, often referred to as nursing home elopement, can result in serious injuries like fractures from falls, heat stroke or hypothermia in extreme weather conditions. It is generally accepted that preventative measures by a nursing home can eliminate or greatly reduce the risk of serious injuries from nursing home wandering. Facilities can train staff, move high risk patients near the nurses stations, use door alarms and security cameras and lock sections of the nursing home where residents who are prone to wander are housed.

According to the complaint, Carrie Evans was diagnosed with bipolar disorder and hypertension, required medication to stay lucid and had problems sleeping that would increase the risk that she may attempt to wander from the nursing home. Primrose staff was well aware of her propensity to wander off, but did nothing to stop it.   There were no staff members on duty that evening to give Evans her medication, and a security system designed to residents from wandering off was broken and had not been inspected since 2005.

Following Evans’ death, the Harnett County Department of Social Services has levied fines against the Primrose facility for multiple safety violations, including a fine for not properly supervising residents in a situation that leads to severe injury, and for not correcting care quality issues that the state has identified within a reasonable amount of time.

The agency’s inspectors also noted a lack of training for non-licensed staff at the facility on several occasions, and the state has felt the need to conduct 28 investigations on Primrose in the last two years, compared to the state standard of four investigations per year.


CBS2Chicago had a tragic story of a nursing home resident found on train tracks near the facility.  There is no excuse for this kind of neglect and lack of supervision.  The nursing home has been sued for negligence after a resident with dementia was discovered lying on train tracks and suffering from cold exposure eight hours after wandering off during a group field trip. McCauley suffered from various psychological and physical conditions, severe dementia and Alzheimer’s disease and required full-time supervision by staff.

Wayne Marz, the guardian of Margaret McCauley, filed the suit in Cook County Circuit Court against Sunrise Senior Living Services, the Brighton Gardens Assisted Living of Orland Park and the home’s Activity Director Debra Ann Adler, following the Dec. 2, 2007 incident that left the woman with significant injuries.

McCauley wandered away unnoticed and was found approximately eight hours later just one mile away, lying on train tracks with visible injuries she had suffered from falling down and from being exposed to cold temperatures for an extended amount of time.

The suit alleges Adler and the nursing home failed to properly monitor McCauley; failed to assess her risk of wandering off; failed to provide an adequate number of staff for residents and failed to ensure her safety.  The center also failed to take proper steps to ensure McCauley’s safe return after discovering she was missing.