The Hilty Home resident who died of hypothermia earlier this month had a history of exit seeking behaviors and the facility failed to ensure adequate supervision was provided, according to a report released by the state health department.
Phyllis Campbell, 76, died Jan. 7 outside the Pandora nursing home.
Campbell left the building around 12:35 a.m., according to the report. Putnam County Coroner Dr. Anne Horstman determined that she died between 1 and 2 a.m.
Campbell was noted to be fidgety on Jan. 6 and wanted to walk and leave the facility, according to the report.
An STNA put her to bed around 9:30 p.m. At 9:50 p.m., Campbell was observed at the east nursing station getting snacks.
Between her bed and the nursing station, Campbell went through a set of doors whose alarm should have gone off but at times would not sound when she went through.
A licensed practical nurse said the last check on Campbell was performed around midnight.
Two state tested nurse aides said they did not check on Campbell at 2 a.m. and 4 a.m., even though checks were documented as being done.