State investigators are faulting the operators of a Minneapolis assisted-living residence for the death of a 76-year-old dementia client who sneaked outside on a winter afternoon and was found hours later in a snowbank.
Kum Sun Melcher, 76, slipped out of the Golden Nest residence in early March and was located nearby suffering from extreme hypothermia.
She was taken to Hennepin County Medical Center and died there that night, the county Medical Examiner's Office said.
Golden Nest "failed to properly assess the client's needs, failed to properly secure an exterior door lock, and [a] staff member failed to properly secure an interior door lock," according to the state Health Department's findings released this week by the agency's Office of Health Facilities Complaints (OHFC).
"The facility was not equipped to provide a secured environment for a client with dementia," the report continued. "The facility did not immediately identify that the client was missing and did not promptly contact emergency services once the client's absence was discovered."
Video surveillance showed Melcher leaving through the lobby without a coat or her cane, the investigative report read. She was shown leaving the property about 2:40 p.m., the state report read. Two hours later, a nurse noticed her missing and wanted to call 911. But the nurse was told to wait while staff looked for Melcher.
The 911 call was made at 5:40 p.m., three hours after Melcher left.
The temperature was slightly above freezing when she walked away and in the low to mid-20s by the time she was found. She was located in an area a police report described as "treacherous," dark and near train tracks.
