TRINITY, Fla. — A new state inspection report reveals that the Waverly Assisted Living Facility in Trinity, Florida "failed to provide adequate personal supervision and oversight" on the night a dementia patient wandered into a walk-in freezer and later died of hypothermia.
William Eugene Ray, who had dementia, got out of bed and left his room just after 12:30 a.m. on September 26.
Watch report from Adam Walser
His family had installed a Ring camera in his room due to staffing concerns at the facility.
Ray's daughter Kristen Spencer woke up to discover her father was missing from his room.
“I couldn’t even believe the words I was hearing”
She called the facility to notify staff, then drove there with her mother.
They were placed in a conference room while staff searched for Ray.
"The director came in and said they found him. And then she said he was in the freezer," Spencer said. "I couldn't even believe the words that I was hearing."
The 54-page report from the Florida Agency for Health Care Administration (AHCA) offers explanations of what happened that night.
Attorney Stephen Barnes, who represents Ray's family, said the state conducted a thorough investigation.
"The state did its due diligence. They not only talked to the administration. They talked to employees, they talked to staff, they talked to residents and got the complete picture," Barnes said.
Report says one employee was scheduled to care for 48 residents
The report reveals that only one staff member was scheduled to work that night in the assisted living side, which had 48 residents.
The report says two people were assigned to the memory care section of the facility.
According to the report, an employee told investigators they had complained to the administrator days before the incident, saying, "We are always short-staffed. We don't take breaks and there are no breaks at night."
The report indicates video from the facility showed Ray wandered around unnoticed for hours, "entering and exiting the kitchen area and the kitchen's cooler multiple times”.
"How could this happen? Basic safety measures were not in place to secure the kitchen," Spencer said.
The report says a cook told investigators, "There was no way to lock the double doors leading to the kitchen, and the key to the fridge was missing, so the door could not be locked."
The Cook said a previous complaint was made to the administrator.
"I was concerned someone would come in and turn the stove on and start a fire,” the cook told investigators, according to the report.
"The kitchen staff told the facility. We can't lock the kitchen doors. We can't lock the freezer. And sounded like it happened more than once that they were asking for this to be taken care of. That simple remedy stops this from ever happening," Barnes said.
Report: Ray was left in freezer for “20 to 30 minutes” after he was found by employee
Ray was last seen on video at 4:30 a.m.
He was found inside the freezer at 8:10 a.m., lying on his side and shivering.
The report says he responded to commands by nodding, even though he could not speak.
The staff member who found Ray didn't move him, claiming it was against facility policy, and instead waited "20 to 30 minutes" for rescue workers to arrive.
"The family's devastated to learn that the patriarch of that family was left in a freezer after he was discovered still alive until the emergency personnel got there, and the excuse was that's the way we were trained," Barnes said.
Ray was taken to Trinity Medical Center, which is just a few hundred yards from the facility, but by the time he arrived, it was too late.
Spencer said she was told by medical staff that Ray’s core body temperature was 66 degrees when he arrived.
According to a report from the Pasco County Medical Examiner, the preliminary cause of death was hypothermia.
Barnes says he hopes the facility will learn from the tragedy, so others’ safety is not put at risk.
"Do your job. You know, if you're gonna take these residents in and you're gonna tell a family that you're gonna take care of them, do your job," Barnes said.
The Waverly did not respond by our deadline to requests for comment about the state report.
To check out nursing home inspection records:
https://quality.healthfinder.fl.gov/report-guides/nursing-homesfl
To check out assisted living facilities in Florida:
https://ahca.myflorida.com/health-quality-assurance/inspection-reports-for-health-care-providers
Share Your Story with Adam
Adam Walser has spent more than a decade fighting for what’s right in Tampa Bay as part of the I-Team. He’s helped expose flaws in Florida’s eldercare system and held leaders accountable for how they use your tax dollars. Reach out to Adam with any issue you think he needs to investigate.
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