88-Year-Old Man Dies after Ivy Manor Cited for Letting Him Leave without Supervision

Posted on behalf of Jeff Pitman on March 3, 2015 in Nursing Home Abuse
Updated on February 24, 2022

An 88-year-old man died Sunday night after walking out of a community-based assisted living facility. Jackson police are investigating the incident, which happened at Ivy Manor on March 1.

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According to authorities, staff realized the man was missing and began a search at approximately 7:20 p.m.

He was found unconscious at 8:37 p.m., just over 100 ft from the door.

Staff immediately called 911. Jackson police were first on the scene and administered CPR, as well as an external defibrillator. Jackson and West Bend Fire Department EMTs then arrived, and the man was transported to St. Joseph’s Hospital.

He was pronounced dead at 10:49 p.m.

The man, who suffered from dementia, is scheduled for an autopsy this morning.

As reported by Darica Williams of Fox6 NOW, a former Ivy Manor staff member said that this could have been prevented.

They should have had an alarm on the door where he would wear a bracelet and he would get probably 10 feet from the door, the alarm would go off. And to notify us if he would get close to the door so we could go. They never put him on that, said the former employee.

The facility’s knowledge of the patient also forewarned of this preventable tragedy.

Wisconsin Department of Health Services documents reveal the patient enjoys walking outdoors and that he actively attempts to leave the building. The man successfully left the building without supervision in August and again in January.

Ivy Manor received two citations related to those incidents, and says it made “safety adjustments” just a week and a half ago in response to the violations.

Their response? Increase the patient’s supervision and monitoring. Records show that in recent months, he was only scheduled to be outside three times per month.

According to Fox 6 NOW, the facility “had not thought of’ including supervised walks as part of the patient’s regular activities.

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