Outer gate left unlocked; woman froze

A Minneapolis assisted-living facility and one of its maintenance workers are being blamed for poor supervision of a resident with Alzheimer’s disease who wandered outside and died of hypothermia in November.

The Minnesota Department of Health determined the woman left through an external gate at the Jones-Harrison Residence that was supposed to be locked, and her caregivers waited too long to initiate a missing-person search, according to a state investigative report released Tuesday.

The woman, who was not named in the report, was found dead in a wooded area near the facility, which is close to Cedar Lake. She was discovered about 11 a.m. Nov. 22 — roughly 19 hours after caregivers last reported seeing her.

“Although staff had an opportunity to intervene, no one implemented the missing-resident protocol in a timely manner,” the report concluded.

The state’s finding concluded that Jones-Harrison was responsible for neglect of supervision. No fines were issued because the state found on a March re-inspection that the facility had corrected its deficiencies.

Police found tracks from a walker on the floor of the facility’s underground garage. They surmised the woman used her walker, which was found near her body, to wheel across the garage and out a gate that led to the woods.

The gate is typically locked after hours, but a maintenance worker admitted he had used the exit at the end of his shift Nov. 21 as a shortcut to his car. He failed to lock it or report it unlocked, according to the report.

A home health aide recorded that the woman ate lunch Nov. 21, and a volunteer reported that she was in the gift shop about 3 p.m. After that, the state report indicates substantial confusion over whether she was out on a facility movie night or away with her daughter. Her absence from dinner and her scheduled medication times prompted three calls to her room that went unanswered.

Complicating matters was the fact that the woman’s daughter took her out Nov. 20 but failed to sign a required form when she brought her back later that day.

A nurse called the daughter about 10 p.m. Nov. 21 to check whether the resident was with her. But a search for the resident didn’t start until after 7:30 the next morning, when the daughter called to report her mother wasn’t with her.

The state pointed out several missed opportunities: A home health aide waited too long to report the absence to a supervising nurse, and the staff waited too long to initiate a search after that. Confusion over the failure of the daughter to sign her mother back in could have been addressed by checking subsequent meal records.

Leaders at Jones-Harrison have taken steps to prevent future incidents. The maintenance worker who opened the locked door was fired. Staff received new instructions on how to address confusion over a resident’s whereabouts and to track residents participating in off-site activities such as movie nights. Keys to the locked door were restricted, and an extra alarm was installed.

“This was an incredibly sad day for Jones-Harrison — one we’ll never forget,” said Lowell Berggren, president and CEO of the senior living complex.

Berggren said the facility will not appeal the state’s finding.

Jeremy Olson can be reached at 651-228-5583.