Nursing Home Resident Dies From Exposure

According to an article on the Canton Rep.com, a resident of a nursing home in Canton, Ohio was found dead after he wandered out of the Glenwood Care & Rehabilitation, located at 836 34th St. NW. The resident had a history of elopement, and was actually picked up by the police who were unaware that the resident had dementia.

The article on the Canton Rep.com states that:

A dementia patient with a history of escape attempts made his way out of a local nursing home, later telling police who found him he wanted to go home to Alliance.

What police didn’t know was Mark Billiter had slipped out the care facility where he had lived for years. They drove him as far as they could — to the city limits. He was found dead there two days later.

Nursing homes are supposed to create a safe environment for their residents, which includes keeping them from wandering off. This horrific and tragic incident could have been prevented.

Risk Factors for Elopement and Wandering Off

The resident’s own past behavior can be a red flag or warning sign for elopement, too, such as prior wandering off that did not lead to injury.  If someone has eloped but been recovered safely, that means they are at risk of elopement and that risk must be addressed by the nursing home.

When an older person’s physical abilities remain, but their cognitive abilities fade such that they can no longer consistently recognize dangers and keep themselves safe, they are at risk of wandering off injuries or death.  Nursing homes must protect residents at risk of wandering off.

Residents with cognitive issues that affect their judgement are particularly at risk for elopement. This is important to be aware of as you search for potential care facilities for your loved one.

Resident’s History of Wandering

Mr. Billliter had a history of wandering off. This particular incident was described in the article as follows:

Police reports released Thursday indicate he used the elevator security code and walked out while following another patient’s visitor. A nursing home staff member ushered them both out, the reports show.

Mr. Billiter’s family said that he was a known risk and that is why he had been residing in a secure unit of the nursing home. The article states that:

Billiter “is from (the) Alliance area and is always wanting to go home. He has also obtained the code to the secure elevator in the past and was known to always try to break out of the facility.”

The first thing every nursing home must do is an adequate assessment of the resident’s needs—at admission, and periodically thereafter—as required by federal regulation § 483.20 (“resident assessment”).  This includes identifying cognitive, mood, and behavior patterns, and “develop[ing] a comprehensive care plan . . . to meet a resident’s medical, nursing, and mental and psychosocial needs.”

Nursing homes can reduce the risk of wandering and elopement injury by implementing appropriate policy and procedure, staff training, and quality assurance/improvement activity.  Every nursing home must have an elopement plan for high risk residents.  This can include a bracelet on the wrist or ankle identifying the resident as a fall risk and placing photos of the high risk residents at all exits and doorways.  Residents can be provided personal alarms to notify the staff if they attempt to leave the facility.  Staff should be trained and required to regularly monitor at-risk residents to prevent them from wandering from the facility.

Doors at the facility should have alarms to notify the staff if a patient is leaving out of a side door or emergency exit.  Many times these alarms are disabled of simply do not work.  Other times, the doors are not securely closed and locked.

Police Picked Up Resident Before He Died from Exposure

Police received a report of a man walking around, they responded and found Mr. Billiter. Mr. Billiter was not a missing person because the nursing home had failed to report him missing. The police then drove him to the city limits, because he was claiming he needed to get to Alliance.

The article states that:

The responding officer stopped him, spoke to him and “ran him through the system. There was nothing on him because he hadn’t been reported missing,” Kurzinsky said. ”(Billiter) requested a ride. He was trying to get to Alliance, to a family member. We were able to transport him to a gas station just a little bit outside the city.”

Billiter’s conversion was recorded by the officer’s body camera.

You can see the body camera video here.

The nursing home had failed to respond and report the resident missing. According to the article, it was the victim’s sister who ended up reporting him missing.

Billiter’s sister called police at 7:51 a.m. Monday to report he was missing from the nursing home.

She told them he stayed in the secured area at the nursing home and disappeared sometime during the night. She said the staff did not notify the family until 7 a.m. Monday, roughly 11 hours after the video shows him leaving the facility.

The victim was found in a particularly gruesome way. He was found behind a dumpster, curled up, and alone. The article states that:

Stark County Sheriff’s deputies called Canton police at 5 p.m. Tuesday, saying the missing man was found dead “by a fueling depot behind a dumpster,” Canton police reports show.

Officers also were told there is video of the location. In it, Billiter walks behind a dumpster around 1 or 2 a.m. Monday when a vehicle pulls onto the lot, the reports state. At 6 a.m. Monday, as the sun rises, the video shows the man “curled up on the ground,” according to the reports

This terrifying tragedy could have been prevented. The nursing home could have reported the resident missing, the police could have identified him as missing, and he could have been returned. Alive.

If some one you love has a history of elopement or wandering off, and has suffered serious injury or worse, has died, please contact me. I will launch an investigation and determine if and how the nursing home could have prevented it. You can comment below or contact me here.

You can access the full article and video here.