Editor's note: This story was originally published in the Belleville News-Democrat.
The State of Illinois has cited the assisted living facility Aspen Creek of Troy and fined it $4,000 after a resident with dementia wandered outside into below-freezing temperatures and died last month.
Kathleen “Kitty” Kinkel, 77, was found dead in a field near the back of the facility six hours after she left the building on Jan. 31.
Aspen Creek specializes in caring for people who have dementia.
Following an investigation, the Illinois Department of Public Health accused Aspen Creek employees of failing to supervise Kinkel and follow facility policy when she triggered the door alarm.
The case remains under investigation by the Troy Police Department and the Madison County Coroner’s office. Troy Police Chief Brent Shownes said Tuesday they are still waiting on a final cause of death report, pending the results of toxicological and microscopic tests.
Aspen Creek officials could not immediately be reached for comment Tuesday.
Illinois Department of Public Health inspectors reviewed video and documents at Aspen Creek and interviewed staff members during its investigation of Kinkel’s death. The Belleville News-Democrat obtained their investigative report and notice of fines through a public records request this week.
State investigation finds violations
Video showed that Kinkel put on her coat and went outside at 2:14 a.m., according to state inspectors. They estimated she walked 54 steps from the back door of the facility.
Aspen Creek’s exits are designed to remain locked unless someone applies continued pressure to the door for 15 seconds, known as delayed egress, after which an alarm will sound. Staff members use keypads to enter and exit.
Two resident assistants on duty responded to the door Kinkel exited within minutes of the sounding alarm but reported they did not see any person or footprints in the snow, according to the state’s review of video and employee statements. One of the resident assistants looked in Kinkel’s room twice without going inside and reported it looked like she was lying in bed.
The resident assistants first noticed Kinkel was missing from her room around 5:30 a.m. They thought she might have been in a friend’s room but did not check because they got busy, according to the state investigation.
An employee who worked the morning shift at 6 a.m. that day told a state inspector that the resident assistants said all residents were accounted for.
The morning shift staff realized Kinkel was missing around 8 a.m. and saw her purple jacket in the field from a window, employees told the state. They ran to the field, found Kinkel without a pulse and not breathing and called 911.
Kinkel was admitted to the facility about a month before her death. She had worked as a real estate sales associate for 26 years and was a member of the St. Jerome Catholic Church in Troy, according to her obituary. Kinkel is survived by her husband, three children and two grandchildren.
Policy review, training to follow resident death
Aspen Creek has since reviewed its wandering and missing resident policy and procedures with all staff members and retrained them on how to respond to door alarms, according to a statement to the state about how it planned to address the issues identified by the investigation. Facilities are required to submit these plans under federal and state law.
The facility also wrote in the statement that it plans to install floodlights with a motion sensor outside each fire exit.
The state cited Aspen Creek for “Type 1” violations, which are the most severe because they are related to severe harm or the death of a resident, and levied the highest fine allowed by state law.
Lexi Cortes is a reporter with the Belleville News-Democrat, a news partner of St. Louis Public Radio.
