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Elderly woman’s hypothermia death triggers $10,000 fine, criminal charges
['Clark Kauffman', 'More From Author', '- April']
Date: 2022-04-08 00:00:00
An assisted living center where a resident froze to death in January has been fined $10,000 by the state.
Courtyard Estates at Hawthorne Crossing in Bondurant is accused of violating state regulations for dementia-specific assisted living centers by failing to have its staff monitor residents. The center is also accused of failing to ensure that all workers have at least eight hours of dementia-specific training within a month of being hired.
State records indicate an employee of the center reported for work at about 5 a.m. on Jan. 20 and noticed that a computer showed one of the door-alarms in the building was activated. The worker told inspectors she immediately dropped everything and searched the area, eventually finding a resident of the center, 77-year-old Lynne Stewart, lying on the ground, unresponsive, just outside one of the exit doors, with various items frozen to her body. The temperature outside that morning was about 11 degrees below zero.
Employees brought Stewart inside, covered her with blankets and called 911. Stewart was wearing a sweater, pants and shoes, but no coat, hat or gloves, according to state inspectors. An ambulance crew arrived and took Stewart to a nearby hospital. Just before 9 a.m., the county sheriff arrived at the home to investigate the matter and informed the staff that Stewart was dead.
Inspectors later reported that hospital records showed Stewart arrived in the emergency room suffering from hypothermia, was stiff and had “ice freezing on her.” She had no pulse in the emergency room, and her body was reported to be too cold initially for the staff to obtain a temperature. Emergency room workers eventually recorded a body temperature of 77 degrees and Stewart was declared dead. The Polk County medical examiner’s report listed the cause of death as hypothermia.
Inspectors’ interviews with Courtyard Estates employees and a review of company records indicated although the woman had a documented history of wandering, her door alarm often wasn’t functioning properly and sometimes sent out erroneous alerts. In other instances, her door alarm was triggered but failed to send a message to the staff via the iPads the employees carried with them.
“All staff knew the door alarm failed to work properly and the issue was discussed at team meetings,” state inspectors later reported. “The maintenance man failed to fix the issue before he left employment.”
Although the staff was to make hourly, visual checks on the woman, the inspectors’ review of video captured by the facility’s in-house camera system on the night of Stewart’s death showed that the employee tasked with checking on residents, Catherine Forkpa, never ventured down the hall where Stewart resided.
Forkpa, 30, allegedly told inspectors she remained in the center’s “TV room” from 3:30 a.m. to 5:30 a.m. and noticed no door-alarm alerts on her iPad during that time. It “slipped my mind to do safety checks,” she allegedly told inspectors.
The center’s on-call nurse told inspectors she was home that evening and noticed there were on-going alerts appearing on her phone, indicating Stewart’s door alarm had been activated. The nurse allegedly told inspectors that she didn’t take action on the matter due to the fact that she was with her family and because she went to bed at around 9:30 p.m. She reportedly told inspectors she had ignored similar alerts in the past because Stewart was known to open her door constantly.
Forkpa has been criminally charged with dependent adult abuse and intentional reckless abuse in connection with Stewart’s death. According to county investigators, Stewart’s door alarm was activated for nine hours before her body was found, during which time Forkpa can be seen on video walking about the facility without the iPad that received door-alarm alerts.
In August 2020, Courtyard Estates was fined $1,500 after a male resident of the home wandered away and was returned to the facility by local police. At that time, inspectors noted that the center acknowledged it had no policy in place regarding regular checks of the door alarms to ensure they functioned properly.
State records indicate Courtyard Estates is owned by a for-profit limited liability corporation called AbiliT Holdings, which was formed by Kevin Russell of Rancho Santa Fe, California. Russell operates Jaybird Senior Living, which manages Courtyard Estates and facilities throughout Iowa, Minnesota, Wisconsin, Illinois and Kentucky.
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