Resident With Brain Injury Escapes Avantara Lake Zurich in Hospital Gown, Found Hypothermic Across Highway

The Illinois Department of Health has cited and fined Avantara Lake Zurich when a severely cognitively impaired resident with a traumatic brain injury escaped the facility through an unalarmed door and was found across a busy four-lane highway wearing only a hospital gown and diaper. The resident suffered hypothermia with a dangerously low body temperature of 93.2 degrees, sustained additional head injuries from falling, and required emergency hospitalization.

The resident in question had been admitted to the nursing facility with severe medical conditions including traumatic brain hemorrhage, heart attack, metabolic brain dysfunction, coordination problems, weakness, and a history of falling. Medical assessments confirmed that the resident was severely cognitively impaired and required assistance with personal care. Due to these conditions, care plans specifically identified the resident as being at high risk for falling and requiring a safe environment with staff supervision.

During the early morning hours, a certified nursing assistant checked on the resident around 3:30 AM and found him sleeping peacefully in bed, wearing a hospital gown and diaper. The assistant noted that the resident was dry and appeared comfortable. However, when she returned approximately 45 minutes later at 4:15 AM, she discovered the resident was no longer in his room.

The assistant immediately contacted the registered nurse on duty to ask if he had removed the resident from bed for any reason. When the nurse confirmed he had not, both staff members began searching the facility for the missing resident. Their initial assumption was that the resident remained inside the building because they had not heard any door alarms, which should have sounded if anyone exited the facility during nighttime hours when enhanced security measures were in place.

As their search continued for 20 to 30 minutes without success, staff became increasingly concerned and contacted the facility administrator. The administrator instructed them to continue searching, and staff spent approximately an hour looking throughout the building before discovering a critical system failure. When they tested the door alarms to verify they were working, they found that the alarms were not activated or were malfunctioning entirely.

This discovery dramatically escalated the situation, as staff realized the resident could have left the building without triggering any warning systems. The nursing assistant later described being “even more terrified” upon learning the security systems had failed. Staff immediately expanded their search to outdoor areas around the facility, including a pond on the property, despite the extremely cold weather conditions.

The outdoor search proved challenging due to the harsh weather. Staff noted that it was “very cold outside” and emphasized their concern that the resident was wearing only a hospital gown and diaper when last seen. The registered nurse on duty confirmed the severity of the weather, stating he “had to get his coat” when searching outside, highlighting the dangerous conditions the resident faced if he had indeed left the building.

After extensive searching both inside and outside the facility proved unsuccessful, staff contacted law enforcement for assistance. Police officers responded to the scene and began their own search efforts. The resident was eventually located by police officers across a four-lane highway from the nursing facility, near a fast-food restaurant. The highway in front of the facility has a speed limit of 50 miles per hour, making it extremely dangerous for a confused individual to cross, particularly someone wearing inadequate clothing in cold weather.

When police found the resident, his condition was alarming. The police report described him as confused and wearing only a hospital gown, with small cuts on his arms and legs and blood in his mouth. Emergency medical services were immediately called to provide medical assistance. The resident’s body temperature when measured at the hospital was 93.2 degrees Fahrenheit, which constitutes severe hypothermia. Normal human body temperature is 98.6 degrees, making this reading dangerously low.

Medical professionals explained the serious health risks associated with such severe hypothermia. The facility’s medical director stated he would be “very concerned” about such a low body temperature and noted that hypothermia “can cause a heart attack, a stroke, or respiratory arrest, then eventually death.” A nurse practitioner confirmed that “the dangers of hypothermia include death,” emphasizing the life-threatening nature of the resident’s condition.

In addition to hypothermia, the resident sustained physical injuries during his time outside the facility. Hospital records documented that he had a missing tooth with dried blood and multiple abrasions on his upper and lower extremities consistent with falling. Medical staff diagnosed him with acute subdural hematoma – bleeding in the brain – in addition to hypothermia and injuries from an unwitnessed fall.

Security camera footage later reviewed by the administrator showed the resident walking out the front door of the facility between 4:05 AM and 4:10 AM, wearing a gown, diaper, and shoes. The administrator noted that while the video showed the resident’s exit, it had no audio component, making it impossible to determine whether door alarms should have sounded.

The facility’s elopement policy stated that “all residents are afforded adequate supervision to provide the safest environment possible.” However, this incident revealed multiple system failures that compromised resident safety. The door alarm system that should have alerted staff to unauthorized exits was not functioning properly during critical overnight hours when enhanced security measures were supposed to be in place.

The resident’s escape and subsequent injuries prompted immediate corrective actions by the facility. Within days, management conducted comprehensive audits of all security systems, implemented additional safeguards including a lock box over alarm system controls, installed new coded entry requirements, and provided extensive staff training on emergency response procedures. The facility also established ongoing monitoring protocols to ensure security systems remain functional and staff respond appropriately to any future incidents.

This case highlighted the particular vulnerability of cognitively impaired residents who may not understand safety risks or recognize dangerous situations. The resident’s severe cognitive impairment, combined with his history of brain injuries and mobility problems, made him especially susceptible to confusion and poor judgment that could lead to wandering behavior. The medical director noted that given the weather conditions and the resident’s compromised mental state, “he could have died” from this incident.

One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.