Staff repeatedly failed to check on Troy assisted living resident found dead in cold

By Pat Pratt

ppratt@timestribunenews.com

Despite the sounding of a door alarm, staff at a memory care facility in Troy repeatedly failed to ascertain the whereabouts of a resident who wandered off and was found six hours later dead in the cold about 50 steps away.

In response to a Freedom of Information Act request, the Illinois Department of Public Health this week provided the initial complaint investigation of the death of 77-year-old Kathleen Kinkel, a longtime and well-known Troy resident.

Troy Police discovered her body at about 8:19 a.m. Jan. 31 in 1900 block of SRA Bradley R Smith Drive, near her residence at Aspen Creek of Troy. 

While video surveillance shows Kinkel leaving the facility just after 2 a.m., the investigation shows facility supervisors did not know she was missing for about six hours, until after 8 a.m. It was not until that time Aspen Creek staff contacted Troy Police, who upon arriving on the scene within minutes found her deceased. 

In the hours between Kinkel’s exit from the facility and the discovery of her body, investigators found multiple missteps by staff in monitoring her whereabouts. The investigation shows those failures to monitor Kinkel’s whereabouts also come following an incident earlier that night where she was upset and telling staff she wanted to go home.  

Video surveillance shows Kinkel put on her coat and was standing at 2:10 a.m. Jan. 31 at the door she exited from. She walked out the door at 2:14 a.m., which triggered an alarm. Three minutes later staff members responded to the door. 

Two staff members looked out the door and the window, stating they did not see any footprints in the snow. Staff told investigators they then checked all the residents’ rooms, but did not go “all the way” inside Kinkel’s, as it appeared from the hallway she was still lying in bed. 

Three more hours would pass before staff would make another required end-of-shift count of residents. Again during the 5:30 a.m. count, staff still did not seek to physically locate Kinkel. 

“When we were doing our last round at 5:30 a.m. we checked on Kinkel, but she wasn’t in her room so we thought she went to her friend’s room,” a resident assistant stated, according to the investigation. “We continued doing our rounds and got busy and didn’t end up leaving until almost 7 a.m. We didn’t go back to confirm if she was in friends room or not.” 

Day shift staff arrived at about 6 a.m. and told investigators that they were informed “everything was ok” and all residents were accounted for. It was not until 8 a.m. that staff coming on-duty realized Kinkel was missing and informed the duty nurse and initiated a search. 

The nurse on duty had staff search every room in the facility for Kinkel. As she entered the third room she was searching, she told investigators she looked out of the window and saw a purple jacket in the field nearby. 

The nurse and staff ran to the location the jacket was spotted and found Kinkel frozen, not breathing and without a pulse. National Weather Service records show the temperature at 7:25 a.m. Jan. 31 about an hour before Kinkel was found, was 11-degrees. The low that day was 11-degrees with a high of 22 later in the afternoon. 

9-1-1 was called and Troy Police arrived within a few minutes. The nurse who discovered Kinkle said she estimated the temperature at the time to be around 18-20 degrees. Her body, according to the report, was located just more than 50 steps away from the door she walked out of more than six hours earlier. 

“The surveyor walked the route out the back door to where (Kinkel) was found in a field located near the back of the facility,” the report reads. “The surveyor took 54 steps, crossing over a small wire fence half-way to where (Kinkel) was found deceased.”