Hospice patient found dead in grass was outside for 7 hours, Michigan officials say
A resident at an adult foster facility was left unsupervised outside at night for more than seven hours before he was found dead, Michigan investigators say.
The patient, identified by WOOD-TV as 83-year-old Calvin Powers, was discovered “face down in the grass” at 2:19 a.m. on Oct. 14 outside American House Senior Living Jenison Cherrywood.
An investigation by Michigan’s Department of Licensing and Regulatory Affairs revealed the patient was 25 feet from his walker and “his whole body was freezing.”
A state investigator is now calling for the Jenison facility’s license to be revoked. Jenison is a suburb of Grand Rapids.
“We are deeply saddened by the passing of one of our residents on October 14, and we are offering our support and condolences to the resident’s loved ones,” American House said in a statement to WXMI. “We respect the state’s advocacy for ensuring the implementation of adult foster care regulations and are working closely with state officials to review their findings to ensure we continue to provide the high-quality care our residents deserve and have come to expect.”
Investigators said in the newly released report that the patient pulled a fire alarm at 7:02 p.m. He was redirected away from the door, but at 7:18 p.m., he was seen exiting the hospice facility through the front door.
Multiple staff members said the alarm was not reset after it was pulled the first time, according to the report. An employee in charge of training staff members and supervising 14 residents said she had not been trained to reset the alarm.
This led to the door being left unlocked and the patient able to get outside without an alarm sounding.
“It was a lot for me and there should have been another person working to train staff,” the worker said of her workload, according to an investigator.
The investigation revealed two workers failed to perform mandatory supervision the night the patient died. Employees are required to check on residents every two hours.
During a 2 a.m. supervision round, one of the workers did not check on the patient because his door was closed, the report said. She had been told the resident “is violent so if his door is shut, don’t go in there.”
The lack of supervision occurred despite the patient’s history of wandering the facility and him exhibiting “exit seeking” behavior, according to the report.
The investigator said the resident experienced “delusions and hallucinations” and was not given his medication the night he died.
He left a different facility at the complex Oct. 4 but was brought back inside by staff. When he left the facility Oct. 17, he was not discovered until seven hours later when he was already dead.
Investigators said the facility violated rules regarding resident protection, application of medicine, staffing and training of workers.
“(The resident’s) protection and safety was not attended to and likely led to his demise,” the report said.
The facility has 30 days to appeal the investigator’s recommendation for its license to be revoked.
This story was originally published November 15, 2023 at 9:48 AM with the headline "Hospice patient found dead in grass was outside for 7 hours, Michigan officials say."