A state investigation into the April 9 death of an 84-year-old resident of Grace Woods Senior Living con- cluded conditions at the facility at the time constituted a “real and present danger” to residents.
The resident who died, Eva Gorosics, wandered away from her room at the assisted-living facility early April 9 and was found dead of apparent hypothermia in the facility’s parking lot about 6:30 a.m., according to Niles police.
Gorosics was one of two residents in Building 2 at Grace Woods, 730 Youngstown-Warren Road, who was cognitively impaired and exhibited wandering tendencies, according to an investigation by the Ohio Department of Health, which also found that Grace Woods had failed to provide adequate staff to monitor residents.
In an April 23 letter to Edward Fabian, Grace Woods administrator, after a state license survey conducted April 13, the ODH Bureau of Regulatory Compliance ordered the facility to correct several violations or face possible loss of its license.
On May 17, however, staff from ODH’s Akron District Office conducted a follow-up inspection and determined Grace Woods had “substantially corrected all licensure violations,” including assigning additional staff to the 11 p.m. to 7 a.m. shift. It also said ODH would continue to monitor Grace Woods’ license compliance status.
Grace Woods officials declined to comment on the matter Thursday.
At the time of Gorosics’ death, only one resident-care assistant, Andrea D. Clark, 27, of Arms Drive in Liberty, was on duty.
Clark, subsequently fired from her job according to the ODH report, is charged with patient neglect in Gorosics’ death. She pleaded innocent to the second-degree misdemeanor charge at her arraignment June 1 and was released on personal recognizance. Her pretrial hearing is July 2.
She was arrested at her residence early June 1 by Liberty police on a warrant issued by Niles Municipal Court and turned over to Niles police, who transported her directly to her arraignment.
Gorosics was in her room at 4 a.m. when Clark checked on her but was missing at 6 a.m., according to Niles police, who were notified at 6:30 a.m. after a search of the other residents’ rooms.
Niles Capt. Ken Criswell, chief of the detective division, said at the time that a facility alarm system designed to alert employees when a door opened may not have been working properly.
“I think there was a malfunction, but there was no time-keeping mechanism to verify that,” Criswell said Thursday, adding, “When we tested the alarm, it went off once and the next time it didn’t.”
Criswell said the case is not complete and that additional charges are possible.
City Prosecutor Terry Swauger said some malfunction of the door alarm may have occurred, but that does not excuse Clark from her responsibility to ensure the safety of the residents.
“The lady [Gorosics] died of hypothermia. It all could have been prevented had she [Clark] fulfilled her duties,” Swauger said.
According to the ODH investigation, the night of Gorosics’ death was not the first time she and another resident of Building 2, which had 30 residents, had wandered.
On April 3, another female resident crawled out her bedroom window. She was seen by a neighbor who called Niles police. Grace Woods staff was unaware she was missing until she was returned by police, according to the ODH report.
Since then, that resident has been discharged and sent to a skilled-nursing facility, and additional staff has been added to the overnight shift. Staff also has been given specific protocol to follow to ensure the safety of residents who wander.
In an interview April 9 with ODH, Fabian said an internal investigation determined that a motion sensor on the ceiling of the therapy-room side of the exit door disarmed the alarm system on the door when it swung open into the therapy room, enabling Gorosics to open the door without the alarm sounding.
Fabian told the ODH investigator he thought Gorosics got outside by walking through the therapy room, up a ramp and through another door into a corridor that would allow exit to the front of the building and into the parking lot.
Clark told the ODH investigator she had told facility nurses that there was too much work for one person, including doing laundry cleaning the kitchen and bathrooms in addition to monitoring residents.
Gorosics was supposed to be checked every 30 minutes, and at 4 a.m. was in her room. When Clark checked at 5:30 or 6 a.m., Gorosics was not there.
Clark said she did not hear any door alarms and that in her search for Gorosics, she found the back therapy room door open.
A Trumbull County coroner’s investigator said a ruling on the cause of Gorosic’s death is pending completion of the police investigation.