Michigan officials say a patient found dead in the grass had been out for 7 hours
The patient, identified by WOOD-TV as 83-year-old Calvin Powers, was discovered “face down in the grass” at 2:19 a.m. on Oct. 14 outside American House Senior Living Jenison Cherrywood.
An investigation by the Michigan Department of Licensing and Regulatory Affairs revealed that the patient was 25 feet from his treadmill and his “entire body was frozen.”
A government investigator is now calling for the Jennison facility’s license to be revoked. Jennison is a suburb of Grand Rapids.
“We are deeply saddened by the passing of one of our residents on October 14, and offer our support and condolences to the residents’ loved ones,” the American House said in a statement to WXMI. “We respect the state’s call to ensure implementation of adult care regulations and are working closely with state officials to review their findings to ensure we continue to provide the high-quality care our residents deserve and expect.”
Investigators said in the newly released report that the patient pulled the fire alarm at 7:02 p.m. and was redirected away from the door, but at 7:18 p.m., he was seen exiting the nursing facility through the front door.
Several employees said the alarm was not reset after it was pulled the first time, according to the report. An employee responsible for training staff and supervising 14 residents said she had not been trained to reset the alarm.
This left the door open and the patient was able to exit without an alarm sounding.
“It was too much for me, and I should have had someone else train the staff,” the worker said of her workload, an investigator said.
The investigation revealed that two workers failed to perform mandatory supervision on the night of the patient’s death. Staff are required to check on residents every two hours.
The report said that during the observation tour at two in the morning, one of the workers did not examine the patient because his door was closed. She was told the resident was “violent, so if his door is locked, don’t go in there.”
The lack of supervision occurred despite the patient’s history of wandering around the facility and exhibiting “exit-seeking” behavior, according to the report.
The investigator said the resident suffered from “delusions and hallucinations” and did not receive his medication on the night of his death.
He left a different facility in the complex on October 4, but staff brought him back inside. When he left the facility on October 17, he was not discovered until seven hours later when he was already dead.
Investigators said the facility violated rules related to protecting residents, administering medication, and hiring and training workers.
“The protection and safety of (the resident) was not taken care of and this may have led to his death,” the report said.
The facility has 30 days to appeal the investigator’s recommendation to revoke its license.
Officials say the nurse intentionally gave patients fatal doses “when staffing was low.”
Georgia cops say a resident who was assisted was left outside overnight due to inclement weather