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On the day a 91-year-old grandfather with dementia wandered from an assisted living facility and died, a technician propped open a secure dining room door, hoping her lost dog would return.
The incident was one of two critical violations that inspectors found at Summit Place, in Mooresville, after state investigators looked into the May 10 death of Joseph Clay Johnston, according to a report released Thursday. The violations could result in fines up to $40,000 for the facility.
Among the errors, the staff didn't adequately supervise residents, which “resulted in the death of (Johnston),” according to the report. In addition to the dining room door being propped open, a door to a secure courtyard also wasn't locked. And staff members assumed that a family member had signed out Johnston, even though a sign-out book indicates his family hadn't taken him from Summit Place in nearly a year.
Greg Reid, Johnston's grandson, said his family is considering legal action, but is waiting on an autopsy and a final police report.
“If it happened once, it can happen again and that's the goal – to be able to prevent this from happening again,” he said.
The report omits the names of employees and residents, but provides details of the events leading up to Johnston's death. Summit Place officials couldn't be reached for comment Thursday evening.
Johnston was last seen alive at Summit Place around 1:45 p.m. May 10 when he ate about a quarter of his lunch, according to the report. It was Mother's Day, and the facility was filled with family members, including children, officials at Summit Place have said.
Eight hours after he finished lunch, Johnston's body was found in a field about 400 feet from the facility off Brawley School Road.
On May 10, a family member arrived at 11 a.m. and asked staff members to help groom Johnston because other family members would be visiting later in the day.
That family member left around noon.
Around 3 p.m. a medication aid asked another staff member for help finding her dog. Both noticed that an outdoor gate that surrounded the facility's courtyard had been left opened, though neither closed it until the medication aid returned from the lunch. The gate was never locked or secured that day, according the report.
The first hint that something was wrong came at 4 p.m. that day. An aid went into Johnston's room to prepare him for dinner and he wasn't there.
Another staff member, assigned to take care of Johnston, said, “I think he went out with his family,” according to the report.
Johnston missed dinner, and another aide inquired about his whereabouts and was told that he left with his family.
At 9 p.m., staff members again began to worry and began searching inside the building.
They checked the sign-out book at 9:15 p.m., called the family a few minutes later, and began looking outside around 9:25.
A little more than an hour later, a family member found Johnston at a construction site.
The register at Summit Place showed that Johnston was last signed out in June 2008. Johnston's family members had told officials at Summit Place that he wasn't able to be taken out because he often got short of breath with minimal exertion and was extremely slow.
Reid said his family was still unsettled because the facility “called my mother at 10 at night and said they had seen where she had signed him out earlier in the day. And my mother hadn't even been there that day.”
