Cuyahoga County Prosecutor Michael C. O’Malley announced on March 26, 2025, that a Cuyahoga County grand jury had indicted a 32-year-old woman in connection with the death of an 84-year-old resident at an Ohio nursing home in December 2024.
On December 23, 2024, around 9:15 p.m., the defendant began her shift as a nurse at the facility. She received her assignment, which included the resident who later died. The nurse relieving the previous shift provided a report, noting that the resident was unable to walk independently and that she had last been checked on around 8:40 p.m. At approximately 9:30 p.m., the defendant went to check on the resident, but found the room empty. Assuming the resident had left the facility with family, she continued with her shift.
Later, around 12:36 a.m., after not seeing the resident, the nurse attempted to contact the resident’s family to inquire about her whereabouts. When the family did not answer, the nurse resumed her duties. The following morning, at about 6:30 a.m., she informed her supervisor that she had not seen the resident during her entire shift, prompting the call for a “Code Purple.”
The Warrensville Heights Police Department (WHPD) was then notified. By 8 a.m., other nursing staff discovered the resident outside on the patio, lying on her back. Emergency services responded, transporting the resident to a nearby hospital, where she was pronounced dead.
Subsequent investigation by the WHPD revealed key details. All new nurses undergo four weeks of training, which includes protocols for dealing with missing residents. Nurses are also required to check on residents every two hours. During her shift, the defendant falsified documentation for several required tasks related to the care of the resident. Additionally, an unlocked door near the resident’s room led to a staircase and the patio where she was found. This door locks from the outside, preventing the resident from re-entering the building.
The Cuyahoga County Medical Examiner determined the cause of death to be environmental exposure due to hypothermia. On January 16, 2025, the nurse was arrested in connection with the incident.
Compliance Perspective
Issue
Facilities must identify and assess residents’ risk of leaving without staff notification and develop interventions to mitigate this risk. This includes establishing protocols for evaluating, monitoring, and managing residents who may be at risk of wandering or elopement. Early identification is essential, starting at admission and continuing with periodic assessments, at least quarterly, or more frequently if there are changes in the resident’s condition. Comprehensive care plans for at-risk residents must specify interventions to address these risks. Staff should consistently document their actions in accordance with these policies. Falsifying documentation, whether related to care tasks or resident monitoring, undermines the safety of residents and the integrity of the care process. The facility’s emergency preparedness plan should also incorporate procedures for locating a missing resident. A critical component of elopement prevention involves ensuring all safety measures, including door alarms and security systems, are functional and routinely inspected as part of the facility’s safety protocols.
Discussion Points
- Review and update policies and procedures for preventing resident elopement. They should include protocols for identifying at-risk residents, providing adequate monitoring, and ensuring that security measures (such as surveillance systems and door alarms) are in place and properly maintained. Policies should also emphasize the importance of accurate documentation.
- Train staff on the importance of consistent monitoring, especially for residents with cognitive or physical impairments. This includes the need for accurate, truthful documentation of all care activities and resident checks. Conduct regular elopement drills to ensure that all staff, across shifts, know how to respond if a resident is missing.
- Periodically audit to ensure that risk assessments for elopement are conducted upon admission and updated regularly, at least quarterly or when there’s a change in the resident’s condition. Ensure staff follow through on their assigned checks, document their observations accurately, and maintain compliance with care plans. Audits should also monitor the functionality of security systems.
*This news alert has been prepared by Med-Net Concepts, Inc. for informational purposes only and is not intended to provide legal advice.*
