According to the recent report, staff at the Jones-Harrison assisted living residence “lost” the female resident in the evening on November 21, 2009, believing that she could be at home with a family member. A family member had signed the resident out of the facility on November 20 but had returned her to the facility, forgetting to sign her back in. The family member told investigators that when she arrived at the facility on the morning of November 22, the resident had not been seen inside the facility for approximately 16 hours and the police had not been called.

Due to the confusion, staff members did not know if the woman had returned to the facility or remained at home with her family. Staff members found the woman on November 22 around 10:30 a.m. near a parking garage, frozen with no pulse. Her cause of death was listed as hypothermia from cold exposure.

The ensuing investigation determined that the woman was able to elope from the facility due to a cyclone fence gate that was left open. The woman, who suffered from dementia, walked through the gate into a wooded area. A maintenance worker, who had left around 4:00 p.m. on November 21, admitted to leaving it unlocked so he could quickly get to his car in the cold weather. The maintenance worker, who had been suspended previously, was fired for misconduct and dishonesty due to the lies he reportedly told initially when he explained how he left the facility that day.

The report concluded that the employee and the facility were guilty of negligence in the woman’s death due to the facility’s failure to manage its resident register and failing to initiate a missing persons protocol timely.