Mr. Nicholas Hanson was admitted at age 75 to Seven Oaks Nursing Center in November 1998 from the Veterans Administration (VA) Medical Center of New York, NY. His past health history was significant for three myocardial infarctions and a 1993 stroke with anoxic encephalopathy that left him with vascular dementia. He was known to be a constant wanderer and elopement risk during his stay at the VA Medical Center. The admitting medications included digoxin 0.125 mg QD and Capoten 6.25 mg TID. He was noted to exhibit elopement behaviors soon after admission and was placed on a list of residents who might potentially wander. A picture of him was placed at the front door, although the security officer position at this site had recently been eliminated. Mr. Hanson subsequently eloped from the facility during November 1998, which resulted in a minor head laceration despite his room being located on a second floor locked unit. Risperdal 1 mg QHS was started in December 1998 for behavioral issues. During a follow-up visit in March 1999, Dr. David Smith, the attending physician, noted Mr. Hanson’s behavior and exam were consistent with the diagnosis of dementia and that he was currently stable on Risperdal 1 mg QD. A care plan conference was held during March 1999, and the risk of wandering or elopement was again identified as an ongoing problem. Mr. Hanson was apparently last seen in the facility at 11:00 PM April 10, asleep in his room. He was noted to be missing just after 1:00 AM. Later, it was believed that he eloped sometime during the shift change that began at 11:00 PM. After he was noted to be missing, an in-house search was initiated per the nursing home protocol, but he was not located. The staff on duty then notified the director of nursing, the administrator, the attending physician, Mr. Hanson’s son, and the local police department. The medical director was not notified. The local temperature range from midnight on for the next 24 hours was noted to have been from 36°F to 39°F with moderate to heavy rainfall. At 6:00 AM the next morning Mr. Hanson was found by an employee in a parking lot less than one block from the facility. He was noted to be unresponsive and with no vital signs detected. A 911 call was placed and EMS personnel subsequently transported him to a local hospital. On arrival at the hospital emergency department, his core temperature was reported as 80°F. Despite ongoing rewarming and cardiopulmonary resuscitation efforts, they were not able to revive him, and he was pronounced dead at 11:30 AM. The county coroner performed an autopsy on Mr. Hanson and his immediate cause of death was attributed to “cold exposure.” An investigation was subsequently conducted by a state survey team that did not cite the facility for any violations. The team did note that the staff stated during interviews that all exits were alarmed and/or monitored. A subsequent evaluation by the alarm company certified that all security and monitoring systems, including the six exit doors, were all working properly. The family subsequently filed suit alleging that inadequate monitoring by the facility staff led to Mr. Hanson’s death from hypothermia. The attending physician and medical director were not named in the suit, but the medical director was called as a plaintiff witness during deposition.