Death of elderly woman from hypothermia leads to $10,000 fine and criminal charges

An assisted living facility where a resident froze to death in January has been fined $10,000 by the state.

Courtyard Estates at Hawthorne Crossing in Bondurant is accused of violating state regulations regarding dementia-specific assisted living centers by failing to have residents monitored by its staff. The center is also accused of failing to ensure that all workers receive at least eight hours of dementia-specific training within a month of being hired.

State records indicate that an employee at the center reported to work around 5 a.m. on January 20 and noticed that a computer showed one of the building’s door alarms was activated. The worker told inspectors she immediately dropped everything and searched the area, eventually finding a resident of the center, Lynne Stewart, 77, lying on the floor, unresponsive, just outside one of the exit doors, with various frozen items for her. body. The temperature outside that morning was about 11 degrees below zero.

Employees brought Stewart inside, covered her with blankets and called 911. Stewart was wearing a sweater, pants and shoes, but no coat, hat or gloves, inspectors said. State. An ambulance crew arrived and took Stewart to a nearby hospital. Just before 9 a.m., the county sheriff arrived at the home to investigate the matter and informed staff that Stewart was dead.

Detectives later reported that hospital records showed Stewart had arrived at the ER suffering from hypothermia, was stiff, and had “ice on her.” She had no pulse in the ER and her body would have been too cold initially for staff to get a temperature. Emergency workers eventually recorded a body temperature of 77 degrees and Stewart was pronounced dead. The Polk County medical examiner’s report listed the cause of death as hypothermia.

Inspectors’ interviews with Courtyard Estates employees and a review of company records indicated that although the woman had a documented history of wandering, her door alarm often malfunctioned and sometimes sent erroneous alerts. In other cases, his door alarm went off but did not send a message to staff via the iPads employees carried with them.

“All staff knew the door alarm was not working properly and the issue was discussed at team meetings,” state inspectors later reported. “The maintenance man failed to fix the problem before he quit his job.”

Although staff were required to perform hourly visual checks on the woman, inspectors’ review of video captured by the facility’s internal camera system the night of Stewart’s death showed that the employee in charge of verifying residents, Catherine Forkpa, never ventured into the hallway where Stewart resided.

Forkpa, 30, reportedly told inspectors she stayed in the center’s “TV room” from 3:30 a.m. to 5:30 a.m. and did not notice any door alarm alerts on her iPad during that time. It “eluded me to do security checks,” she reportedly told inspectors.

The center’s duty nurse told inspectors she was home that evening and noticed ongoing alerts appearing on her phone indicating that Stewart’s door alarm had been activated. The nurse allegedly told the inspectors that she did not act on it because she was with her family and because she went to bed around 9:30 p.m. She allegedly told the inspectors that she ignored similar alerts in the past because Stewart was known to open her door constantly.

Forkpa has been criminally charged with addicted adult abuse and reckless intentional abuse in connection with Stewart’s death. County investigators say Stewart’s door alarm was activated for nine hours before his body was found, during which time Forkpa can be seen on video walking around the facility without the iPad that received door alarm alerts.

In August 2020, Courtyard Estates was fined $1,500 after a male resident of the home wandered off and was returned to the facility by local police. At the time, inspectors noted that the center acknowledged that it had no policy in place regarding regular checks of door alarms to ensure they were working properly.

State records indicate that Courtyard Estates is owned by a for-profit limited liability company called AbiliT Holdings, which was formed by Kevin Russell of Rancho Santa Fe, California. Russell operates Jaybird Senior Living, which manages Courtyard Estates and facilities in Iowa, Minnesota, Wisconsin, Illinois and Kentucky.