On February 13, 2025, the Minnesota Department of Health reported that staff at an assisted living facility failed to supervise a resident with dementia, who required safety checks every two to three hours. As a result, the resident left the building and died from cold exposure.
The Office of Health Facility Complaints’ State Rapid Response Investigative Public Report determined that the death was caused by neglect, and the facility was held responsible. The resident, who had dementia and required regular safety checks, eloped from the facility unnoticed. He developed frostbite and hypothermia and was hospitalized, where he died 11 days later.
Despite the resident’s assessment indicating the need for safety checks every two to three hours, staff were directed to check on the resident “as needed.” The failure to perform regular checks led to the resident eloping from the facility. Staff were unaware he was missing until a neighbor found him outside in freezing temperatures.
The resident’s condition, including moderate cognitive decline and a history of falls, was documented upon admission, and his service plan included regular safety checks. However, this plan was not properly communicated to staff. On the night before the incident, staff noted the resident was present during a medication round, but no checks were performed after that. The next morning, a neighbor alerted staff to the resident lying outside, dressed inappropriately for the cold. Emergency services were called, and the resident was transported to the hospital.
The facility’s internal investigation revealed discrepancies in the documentation of safety checks, with no checks recorded during the first month of the resident’s stay or on the day of the incident. Although staff had provided other services after the resident’s hospitalization, safety checks were not conducted as required.
The resident was admitted to the hospital in critical condition, suffering from hypothermia, frostbite, and head trauma. Despite efforts to stabilize him, he died 11 days later. His death was ruled an accident caused by cold exposure.
The Minnesota Department of Health substantiated the neglect claim made by the Office of Health Facility Complaints, confirming that the facility’s failure to provide appropriate supervision directly contributed to the resident’s death.
Compliance Perspective
Issue
Facilities must assess and address the risk of elopement for residents, particularly those with cognitive or physical impairments, by implementing clear policies and procedures to identify, monitor, and manage at-risk residents. Early and ongoing assessments, including quarterly evaluations and reassessments following any change in condition, are essential to determine elopement risks. At-risk residents should have specific interventions included in their comprehensive care plans to address elopement risks. Staff must document the implementation of these policies. Additionally, the facility’s disaster and emergency preparedness plan should include protocols for locating a missing resident. A critical component of elopement prevention is ensuring that all safety alarms, including door alarms, are functioning properly. Regular inspections and maintenance of these systems should be part of the facility’s ongoing safety protocol.
Discussion Points
- Review and update policies and procedures related to preventing resident elopement. These should include clear protocols for identifying residents at risk, ensuring adequate monitoring and staffing levels, and implementing security measures. Facilities should regularly evaluate the effectiveness of both physical systems (like door alarms) and surveillance systems (like cameras), ensuring they are functioning properly and providing sufficient coverage.
- Train staff regularly on the importance of resident monitoring, especially for those with cognitive or physical impairments. Provide ongoing, refresher training to ensure that all staff, including new hires and those across different shifts, are familiar with elopement protocols. Regular elopement drills should be conducted to ensure staff can act quickly and appropriately in a missing resident situation.
- Periodically audit to ensure elopement risk assessments are completed upon admission and updated at least quarterly or when a resident’s condition changes. Use audits to assess compliance with care plans, monitor the implementation of safety checks, and identify areas for improvement. Audits should also include checks on the functionality of security systems like door alarms and tracking systems.
*This news alert has been prepared by Med-Net Concepts, Inc. for informational purposes only and is not intended to provide legal advice.*
