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Mistakes could have played role in woman's death, report shows

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CONCORD, N.C. -- A state investigation shows that a nursing home in Concord made several mistakes, which could have played a role in the death of a patient.

The 21-page report says that the staff and director of Five Oaks Manor knew that 87-year-old Annie Bell Scarboro could be in danger because she had wandered off before.

The first time Scarboro was found safe and sound. But the second time Scarboro fell from a loading dock and died.

Scarboro's daughter told NewsChannel 36 that she believes her mother's death could have been prevented.

"I put her there trusting that they would keep her safe and then this happened. It's not right," Rosemary Ritchie said in December.

State inspectors from the Department of Health and Human Services went into Five Oaks Manor in December after the Alzheimer's patient died. The report shows Scarboro got through three sets of doors unsupervised.

First, she went through the dining room doors. A worker says those doors hadn't locked properly for at least eight months.

Then, Scarboro went through the kitchen doors and out a back door leading to the loading dock. The back door, according to the report, had no alarm.

"Mom didn't deserve what happened," Richie said.

Scarboro fell 4 feet off the loading dock .The "merry walker" chair she used to get around landed on top of her.

A nurse who found Scarboro told inspectors, "I went out there and saw her blood was running everywhere."

Scarboro's family is angry because the Alzheimer's patient had gotten out the same way before. A nursing assistant at Five Oaks told investigators, "Everyone knew that she wandered around.  We all knew that she did that. She got out that kitchen door before."

The report shows that on May 22, 2008, Scarboro had exited the building through the same kitchen door. That time she wasn't injured.

The solution then was to check on her every 15 minutes.

She had been missing that long in December when the staff realized she'd taken the walk that led to her death.

"I feel like I let my mom down, but the nursing home let me down," Ritchie said.

The state investigation found the nursing home failed to meet several federal standards of care, meaning Five Oaks could be forced to pay a big fine and could lose their funding altogether.

NewsChannel 36 tried to get comment from the director, but he hung up on us.

According to the report, Five Oaks has made some changes because of Scarboro's death. There is an alarm now installed on the back door, the locks have been fixed, and a fence was installed along the loading dock.

To view the full 21-page report, click here.