Nursing Home Lets Resident Die 30 Feet From Front Door in Freezing Cold

A view of an open red door with push-bar handle to the left of the frame, exposing an out-of-focus hall.

Nursing homes that allow dementia residents to wander outside put them at risk of serious injury or death (called “elopement”).

A nursing home should never allow a resident to wander outside in the bitter cold and freeze to death.  It seems so simple a rule.  Yet it happens, all to often: nursing home residents who are known wanderers are allowed to leave (“elope” from) the nursing home without anyone noticing.

It’s only the lucky ones who are found safe before tragedy—freezing to death, overheating, being struck by traffic—takes them.  The fact is, nursing home wandering off is a real and deadly threat.

That’s what happened to 76 year old Ohioan Phyllis Campbell, someone the nursing home knew was at risk of wandering due to dementia.  She left an Ohio nursing home in the freezing cold despite having a device on her that should have sounded alarms.  She wasn’t found until the next morning, after it was too late.

She was only 30 feet from the front door.

As WTVG Channel 13 reported:

The woman, who earlier in the day told a nurse’s aide she was going home, went through a door into a courtyard even though she was wearing a monitor that should have set off alarms, the report said.

Two aides told investigators they did not do scheduled checks that night even though they were marked as completed, according to the Ohio Department of Health investigation.

A coroner determined that Phyllis Campbell, 76, likely died an hour or two after she went outside the Hilty Memorial Home in Pandora, roughly 50 miles (80 kilometers) southwest of Toledo.

She was found in the courtyard about 30 feet from its doors the morning of Jan. 7.

That’s as preventable as it is unacceptable.

When I investigate nursing home death cases, I look at whether the nursing home is to blame for an injury or illness.  The fact is, every long-term resident of a nursing home will die eventually.  That’s nature.  The question is: should they have died then, like this?

When someone with a known history of elopement wanders off into the cold and isn’t found for 8 hour, the answer is a definite: NO.

It is a nursing home’s job to provide the level of care needed to prevent someone with a known risk of wandering from leaving the facility.  Broken equipment and falsified checks are the explanation, but they’re no excuse.

So how bad is this nursing home?

I looked them up on Medicare’s database and learned that it’s got decent ratings (for Ohio):

screen shot of nursing home compare general tab for Hilty Memorial Home in Ohio

Nursing home information is available from Medicare, but do not always trust the numbers. Nursing home lawyers can get better information when something goes wrong.

What I focus on most of the time is staffing.  Bottom line is, without enough nurses or aides, you cannot give good care to everyone.

Here, the nursing home has 4 stars (out of 5) for staffing.  Pretty good—downright above average.  But until you get the real numbers from the facility (or the Medicare database), you won’t know if this is the “real” staffing numbers.


Because for some bizarre reason, Medicare allows nursing homes to get a staffing bump by basing the statistics on self-reported staffing in the two weeks prior to the inspection.  Guess what: nursing homes have a pretty good idea when those inspections are coming, so they staff up to game the system.

Some outright lie.

What I can tell you is, this isn’t the first time nursing staff at this nursing home skipped checks.  Or skipped important care.  Or didn’t bother to fix equipment.  That kind of thing is what happens when you need more people to help care for everyone.

I’m glad the state weighed in and investigated.  But I sure hope the family gets a lawyer on the case who knows this area of the law, and knows where to get the data to prove this was no simple accident.  This was a preventable death.

It was not this woman’s time.

What do you think?  Please take a moment to weigh in below in the comments.

Read more of this story here:

Woman was outside nursing home 8 hours before dying in cold (WTVG Channel 13)

Putnam County officials identify woman found dead outside nursing home (Toledo Blade)

Woman was outside nursing home 8 hours before dying in cold (USA Today)

Ohio nursing home resident out in extreme cold 8 hours before being found dead, report says (

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