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Gilbert memory care center fined $500 after patient walks out undetected and dies

AZDHS fined Silver Creek Inn $500 for the incident, advocates are furious about the amount.

GILBERT, Ariz — A Valley memory care facility is facing multiple citations after one of its patients wandered out of the building and was found dead about two miles away.

Ina Jenkins, an 88-year-old who had been diagnosed with dementia, somehow walked out undetected in early August of the Silver Creek Inn Memory Care Center in Gilbert. 

Hours after she was reported missing to police, they found her body in an irrigation canal, according to a report by the Gilbert Police Department.

For months, it was not known to the public how Jenkins was able to get out of the secure building located on Baseline Road just west of Power Road, but those same police reports show what investigators believe happened. 

During their interviews with staff, police were told all doors have locks and alarms to alert staff when a patient gets out. However, the morning Jenkins was reported missing one of the staff members said a door was propped open by a janitor so they could take out the trash. Through that door, investigators say leads to another area with no locks or alarms and ultimately ends outside the building.

The police report says they found Jenkins dead about a one and a half mile walk away. Police were able to identify her from a picture provided to them by her husband as well as the shoes she was wearing. They had her name, "Ina" written on the bottom of them. 

The Arizona Department of Human Services began its investigation into the facility to see if proper procedures were followed. It learned that the last time anyone had seen Jenkins was at 5:00 a.m. during their hourly check-in with patients. It's investigators discovered that the reports from 6:00 a.m. to 7:00 a.m. were missing. It would be an hour later when AZDHS says a staff member went to check on Jenkins and noticed she was missing.

Silver Creek Inn was cited for multiple reasons including not following proper procedures for patients who may wander, not knowing where patients are, and doors not being locked or alarms set. 

The Executive Director for Silver Creek Inn Bonnie Hollabaugh provided the following statement: 

“Ms. Jenkins was a cherished member of our community. Over the past several months, our team took all appropriate actions to support and cooperate with law enforcement and agency efforts pertaining to this tragic and isolated incident. The safety and well-being of our residents remains our top priority."

The State fined the facility a total of $1,000. Half of that was for the situation that unfolded, the other half was for a staff member that did not have their First Aid and CPR certification up to date.

"That is outrageous," says Dana Kennedy the State Director for AZ AARP. She believes the punishment does not match the behavior. Calling on the state to increase enforcement and oversight to prevent these types of situations.

"We have talked to legislators about increasing the penalties of bad behavior and this is a perfect example of why we need to do just that," Kennedy says.

12News reached out to AZDHS to find out why the fine was set at $500. A spokesperson says state law limits fines to $500 per violation per day.

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