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State sanctions Sun Prairie assisted-living facility after elderly resident froze to death

February 6, 2018

The state has ordered a Sun Prairie assisted-living facility to stop taking new residents and fined the center $4,200 after an elderly resident with dementia was found frozen to death outside late last year.

Alice McGaw, 84, was discovered dead outside of Faith Gardens on the morning of Dec. 29, when the temperature was below 10 degrees.

The facility failed to use a front-door alarm, left an inside door propped open and didn’t check often enough on McGaw, who frequently tried to leave the facility, according to a state Department of Health Services inspection report made public Monday.

McGaw’s family told inspectors they transferred her in October to Faith Gardens, which can have up to 17 residents, after she rolled her wheelchair out the door of another assisted-living facility and was almost hit by a car.

“So the family decided to be pro-active and look for a smaller facility, and with winter coming they wanted a more secure environment,” officials wrote in the Jan. 8 report after their Jan. 3 inspection at the facility.

In a Jan. 23 letter, the health department said Faith Gardens, which had been previously cited for other incidents, could not accept new residents until the new violations were corrected. That is the most serious sanction given outside of revoking a facility’s license.

Managers at Faith Gardens did not respond Monday to a message seeking comment. Efforts to reach McGaw’s family were not successful. McGaw was a former state worker, according to her obituary.

The state actions against Faith Gardens come as a U.S. Government Accountability Office report Monday found huge gaps in the regulation of assisted living. Many states are unable to provide basic information on abuse, neglect or unexplained deaths, the agency said.

Despite the inadequate oversight outlined by the GAO, assisted living continues to grow, in some cases as an alternative to nursing-home care. Wisconsin has nearly 4,200 assisted-living facilities with a total of more than 59,000 beds, compared with about 400 nursing homes with roughly 33,000 beds. Until 2008, beds in nursing homes outnumbered those in assisted living.

The state fined Faith Gardens $2,700 for inadequate supervision, including not checking on McGaw every hour or 30 minutes; $1,000 for not keeping her safe, including not using alarms; and $500 for not managing her behaviors, such as entering other residents’ rooms and trying to leave the facility.

On Dec. 29, a night worker checked on McGaw at midnight and found her sleeping, and at 4 a.m., when she was awake, the worker told inspectors. At 6 a.m., the worker checked again and didn’t see McGaw in her room, “but that is not uncommon,” the worker said.

McGaw was found outside a few hours later.

The day before, after McGaw had been up all of the previous night, an administrator said she should be checked every 30 minutes instead of hourly as before.

Workers said the front door alarm wasn’t used and the inside door was propped open because people used the doors frequently. The night worker typically placed two leather chairs by a door and watched for residents, apparently in an effort to keep them from leaving, the worker said.

McGaw’s care plan called for her to wear an alarm bracelet, but the facility didn’t use the bracelet system, the state report said.