MINNEAPOLIS (WCCO) — The Minnesota Department of Health has concluded that a home care provider’s neglect led to the hypothermic death of one of its dementia patients.

An investigation into the March 16 incident shows staff members at Golden Nest Adult Daycare and Assisted Living neglected to provide adequate supervision for the patient who wandered outside the facility into inclement weather. Video surveillance shows an employee entering the home and failing to close the door securely. The patient is seen exiting the home through the unsecured doors soon after.

It wasn’t until two hours after staff had realized the patient was missing that they notified authorities and filed a missing person report. The patient was found by family in a snow bank at 11 p.m.–almost eight hours after staff first noticed she was missing.

The patient later died in the hospital due to complications of hypothermia.

In an interview with investigators, nursing staff said the patient repeatedly said she “wanted to go home,” but that staff never thought the patient would be “an elopement risk.”

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