TAMPA — One day in January, Maynell Scott pushed open two emergency exit doors at the Belvedere Commons assisted living center and kept walking.
When the alarm sounded, a staffer hustled to the door and caught up with the octogenarian Alzheimer's patient about 25 yards down the sidewalk. At that point, according to the center's policy, Scott should have been flagged as an escape risk and fitted with a GPS wristband.
That never happened.
Failure to follow this policy was one in a series of errors contributing to Scott's drowning six months later in a pond near the center, an investigation by the state's Agency for Health Care Administration has found.
Another error endangered all 22 residents at the "memory care" center — failure to secure and reset the alarmed doors, according to the investigation summary report.
Kathy McDonald, one of Scott's daughters, said the family has seen the report.
The "actions of Belvedere Commons that led to our father's death are unforgivable," McDonald said in a text message to the Tampa Bay Times. "Our family has retained an attorney."
Scott, 81, a native of the Cayman Islands who loved to play guitar, was last seen in the center at 1513 W Fletcher Ave about 6:30 p.m. on Saturday, July 16. Three days later, on the afternoon of July 19, a volunteer hanging flyers showing Scott's photo spotted a body floating in North Lake near Fletcher and North Armenia avenues.
Badly decomposed and mutilated by animals, the body took a while to identify as Scott's, according to a Sheriff's Office report obtained Monday by the Tampa Bay Times.
He was less than a half a mile away from the center he called home.
The morning after Scott disappeared, a man who fit his description was seen knocking on doors in the neighborhood, according to the report. A Hillsborough Sheriff's Office detective told AHCA investigators that, based on Scott's history, he should have been fitted with the GPS "SafetyNet" tracking device.
"He stated if (Scott) had been wearing the SafetyNet the police could have located him before he went into the lake," the report said.
A message left for Belvedere Commons Executive Director Tracey Earle-Crowell was not returned Monday. AHCA records show the center has completed a corrective action plan.
Scott was admitted to Belvedere Commons on Dec. 17. The website of the 38-bed center says it offers "specialized memory care for people with Alzheimer's and other forms of dementia."
A health care assessment form completed at the time said Scott had Alzheimer's and was an elopement risk, meaning he might try to leave, according to the AHCA report.
That's what happened Jan. 5, when a staffer heard an alarm and found Scott outside. The staffer said Scott was most active at night and was able to move around well on his own.
"He moves fast," so she had to run, she told an AHCA investigator. The employee caught up to him about 75 feet down the sidewalk and brought him back inside. She said she wrote a note in his resident log, filled out an incident report and placed it on the desk of the center's wellness director. She also said she called the wellness director and told Scott's daughter
The wellness director, whose name is not included in the report, would later tell investigators she never saw an incident report, didn't remember talking to the staffer, and doesn't review notes in the resident logs.
"She stated no additional precautions were put into place because she was unaware that he had previously been able to get out of the building," the report states. "She stated he should have had a SafetyNet GPS wrist guard obtained for him after his first elopement."
The wellness director completed a new assessment form Feb. 13, once Scott came back to Belvedere Commons after undergoing surgery at a local hospital. The form said he needed help getting around but did not identify him as a risk to leave. The wellness director said she completed the report by reading hospital notes and observing the resident for 24 hours.
She did not interview direct care staff, the nurse who works with the resident, or read the notes in the resident's chart, according to the AHCA findings.
The report also outlines how the center failed to follow its own policies and procedures leading up to and after Scott's second disappearance.
One staffer told investigators that when the door alarm went off that evening, she found another resident in an area between the inner and outer emergency exit doors. The employee, who started working at the center three weeks earlier, didn't check the outer door and didn't notice it was slightly ajar until a supervisor on duty saw a light on a control panel indicating it was still open.
The employee told the supervisor no one had opened the exterior door but that she was looking for Scott. The supervisor told the employee to look outside for Scott. When that turned up nothing, the supervisor directed the employee to go to the nearby gas station to look and told another coworker to search the area by car.
According to the report, under the center's policy, when a resident is missing, staff should search building and grounds for up to 15 minutes then notify the executive director and take another 15 minutes to search by car. After that, the policy says, staff should call police and the resident's family.
Door alarms went off at 6:42 p.m. and 6:45 p.m., but staff did not call Earle-Crowell, the executive director, until 7:48 p.m. The staff contacted the Sheriff's Office at 7:59 p.m., more than hour after Scott disappeared, when the director told them to make the call.
The family found out by chance Scott was missing when one of his daughters called the center and learned a search was under way.
The supervisor on duty that night, who started work three months earlier, said she only knew how to turn off the door alarms and had never participated in an elopement drill. The employee who searched by car also said he'd never participated in a drill.
Based on the findings, AHCA ordered Belvedere Commons to take several corrective actions in a letter Aug. 1. Among them:
• Update its policy and procedures for elopements, particularly for updating risk assessments on each resident and training staff in how to maintain and monitor secure exit doors.
• Update all elopement assessments of its current residents.
• Require staff to participate in elopement drills within three days.
• Implement a policy of periodic checks on residents, especially those with a history of trying to leave the center.
An AHCA investigator visited Belvedere Commons on Aug. 9 and found the center had complied with the directives.
It's unclear if the center will face sanctions such as fines or action against its license. An agency spokeswoman said in an email that AHCA will continue to monitor Belvedere Commons.
The center is managed by Minnesota-based Grace Management Inc. State records show the owner is a limited liability corporation called FKP Tampa Senior Living.
In 2013, Belvedere Commons was flagged by the state for failing to report an incident where a resident left the center. According to a report, the resident broke a latch on a patio gate and was found walking along Fletcher Avenue about 15 minutes later.
Scott's disappearance sparked an intense three-day search by sheriff's deputies and volunteers.
Deputies scoured the area with bloodhounds, talked to neighbors, searched more than a dozen bodies of water and reviewed surveillance video, according to Sheriff's Office reports.
A camera at Village Coin and Stamp, in the Rosewood shopping center near Fletcher and Rome avenues, captured Scott walking along Fletcher at 7:09 p.m. the day he disappeared.
About the same time, Kristen Dill was sitting in her car waiting for the light to change when an older man crossed Rome in front of her. He walked with a slight limp but didn't appear lost or disoriented, Dill said in an interview Monday. At one point, she said, the man gazed up at the sky.
"He just seemed like he was out for a nice walk on a Saturday evening," said Dill, 44.
The next morning, when deputies arrived at her nearby apartment complex with a photo of Scott, Dill realized it was the same man.
"My heart broke because I come from a family that has dealt with the loss of a loved one because of Alzheimer's," Dill said. "I know the hardship and the anguish and the heartbreak that disease brings with it."
Beatriz Cespedes told deputies she saw a man banging on two of her neighbors' doors in the Fletcher's Point townhome community on Fletcher about 10:30 a.m. the morning after he disappeared. He was older, balding with white hair, wearing a dark-colored dress shirt and grey slacks.
Cespedes, whose front door is steps away from North Lake, never saw the man's face before he disappeared.
Contact Tony Marrero at email@example.com or (813) 226-3374. Follow @tmarrerotimes