PANDORA — 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 J. Campbell, 76, formerly of Findlay, died Sunday, Jan. 7, outside the Pandora nursing home, which is operated by Mennonite Home Communities of Ohio.

Campbell left the building around 12:35 a.m. through the dining room exit doors, according to the state report. The temperature was minus 2 degrees and there was snow on the ground.

She was not found for about eight hours, even though checks at 2 a.m. and 4 a.m. were documented as having been done.

Putnam County Coroner Dr. Anne Horstman determined that Campbell 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. She also “kept saying she had to go see her mom.”

Campbell’s mother had preceded her in death, according to her obituary.

One day during the week prior to her death, Campbell had twice gone outside from the “Riverview” memory care unit into a courtyard and returned inside within minutes, the report said. On Jan. 6, she tried to go outside between 2 and 4 p.m., “stating she wanted to go home with her mom.”

A state tested nurse aide (STNA) put Campbell to bed around 9:30 p.m. Jan. 6. She was out of bed “within five minutes,” the report said. 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.

Employees tested the alarm system on the doors the day after Campbell’s death and found that, when the doors were propped open, the alarm did not consistently go off.

Propping open those doors “was a common practice,” the state report said, “to allow staff to freely walk between” Riverview and the other units.

Also, a bracelet Campbell wore “failed to work by activating audible alarms at times,” according to the report.

A licensed practical nurse said the last check on Campbell was performed around midnight. The LPN said she did not check the alarm on the dining room doors — the ones Campbell left through — during her shift.

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,” the report said.

A STNA entered Campbell’s room at about 8:20 a.m. Jan. 7 and found she was not there. Staff began looking for her.

One STNA looked in the courtyard off the dining room because when she arrived for her 2 a.m. shift, “she thought she heard someone talking or mumbling” in that area. According to the report, “this startled her and she came into the building.”

Hours later, the same STNA (and an LPN) found Campbell about 30 feet into the courtyard, near a swing set, with a water bottle and a bag of Combos.

“When the resident was finally discovered by facility nursing staff, she was lying on the frozen ground, pulseless and deceased,” the report said.

Changes made

The report details the following actions taken after Campbell’s death:

  • Three STNAs and one LPN were put on administrative leave on Jan. 8. They no longer work at Hilty Home.

    “The employees involved in this incident are no longer with our organization,” Laura Voth, CEO of Mennonite Home Communities of Ohio, said in an emailed statement.

  • The devices used to prop open the doors have been removed.
  • All door alarms have been checked, and the dining room exit doors now have “a continuous sounding alarm.”
  • All residents “were assessed for risk of elopement.” Eight received new alarm bracelets.
  • The “elopement” policy and procedures were updated, including bracelet replacement every 90 days.

Voth said that the Hilty Home community is “deeply saddened by this loss. We are grieving for the family and extend our heartfelt sympathy to them. Our Hilty Home community is also grieving for the loss of a resident we loved.”

“Mennonite Home Communities, along with the Ohio Department of Health, assessed the safety protocols at Hilty Home to ensure the well-being of all our residents. We were responsive to the situation as noted in the ODH report.

“Mennonite Home Communities and the leadership of Hilty Home are committed to best practices to serve our elders and their families well. We are committed to creating safe and positive environments for those we serve,” Voth’s statement said.

Rubright: 419-427-8417
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Twitter: @kerubright