HUNTINGTON, W.Va. (WSAZ) - For months, WSAZ has been trying to figure out how a man with documented dementia was able to walk away from a hospital and die.

Now, we have answers. A report details a series of deadly deficiencies that led to Charles “Chuck” Carroll’s death.

Carroll went missing Dec. 30, 2021, from Cabell Huntington Hospital after being taken by ambulance from an assisted living facility.

He can be seen in surveillance video wandering in and around the hospital for hours before finally walking away.

More than seven weeks later, his body was found in an outbuilding, just blocks away from Cabell Huntington Hospital.

He was still wearing his hospital bracelet.

Now, about five months later, how this happened is finally becoming more clear after WSAZ obtained new documents highlighting a series of “failures” at the hospital the day Carroll arrived.

Getting these documents though, wasn’t easy.

Since Carroll’s body was found, we’ve been asking the West Virginia Department of Health and Human Resources (DHHR) questions by email.

On Feb. 22, we asked if there was an investigation into protocols since Carroll died after going missing while in Adult Protective Services. We were told the state’s Bureau for Social Services will be reviewing the matter.

On March 3, we asked about an investigation at the hospital and was told the agency’s Office of Health Facilities Licensure and Certification (OHFLAC) was conducting a survey, but “the process can take several months.”

On April 27, WSAZ’s Sarah Sager followed up, asking if the survey was complete.

She received a response on April 29 that reads, “CMS has not approved the report to be released yet.”

We obtained emails between lawmakers and a former DHHR official on March 22 - more than a month earlier - referencing that OHFLAC’s investigation report and citations that were issued to the hospital.

The email chain begins with a senator reaching out to DHHR after hearing from a constituent about our investigation into the timeline of Carroll’s disappearance and death.

The senator says the constituent wanted to know “what could be done to prevent this in the future.”

The former DHHR official responded in part, saying “a lot of things went wrong here on the provider side.” He also included details of the investigation and the citations.

So, WSAZ’s Sarah Sager reached out to CMS. It’s the agency that provides the federal guidelines OHFLAC used in that survey and report.

On May 26, Sager asked if the survey report was ready.

Less than 24 hours later, the results were posted online by the state.

The survey found that each patient has rights under federal guidelines.

According to the report, investigators found deficiencies at the hospital regarding two aspects of those rights.

The first, resulted in what’s called an immediate jeopardy. The report reads in part, “the facility failed to provide care appropriate for a patient who presented to the emergency department with a diagnosis of dementia, which contributed to the patient’s elopement.”

The second deficiency states “the facility failed to ensure care was rendered in a safe setting.”

So, according to the report, not only did the facility fail to provide “care appropriate” for a patient with dementia, the facility “failed to provide adequate re-education to all staff to prevent this from occurring again.”

It goes on to state, “this failure has the potential to adversely affect all patients who present to the ED by EMS.”

The report also lists a lot of information about what went wrong and it starts from the minute Carroll arrives.

Documents sent to the hospital by the assisted living facility revealed Carroll had dementia, but according to the report - that information was never added to his chart.

The report states the triage nurse looked at the papers and gave them back to EMS and the patient, but Carroll can be seen walking to registration without any papers in hand. The report goes on to say, “no one knows where the paperwork is.”

In the report, Carroll’s medical records show he was documented as leaving against medical advice at 6:55 p.m.

There was no documentation the assisted living facility, security or police were notified when the emergency department realized Carroll left.

The supervisor of security says normally nurses inform security a patient with dementia has left and give a description.

The supervisor even says “sometimes security can locate a patient on the grounds.”

Surveillance video shows Carroll leaving the waiting room and walking outside at 6:06 p.m.

Then at 8:17 p.m., more than an hour after he walked away, he’s seen on camera back inside the hospital speaking with a guest services representative.

Had security been notified, Carroll may have been found and taken back to the ER.

But instead, at 8:20 p.m. Carroll walks out of the hospital again and down Hal Greer Boulevard. That’s the last known time he was seen alive.

The report does detail the actions the hospital is taking as a result of the survey.

Some of those include:

• notifying the care facility or next of kin anytime someone over the age of 65 or anyone with a diagnosis of dementia walks away against medical advice or elopes from the hospital.
• emergency department auditing records of all patients who walk away to make sure all protocols were followed.

We asked Cabell Huntington for an interview before the results of the survey were released, but no one ever replied.

When we asked after the results were released, we only received automatic replies stating they are out of the office.

UPDATE: A Cabell Huntington Hospital spokesperson reached out WSAZ on June 9, 2022 saying the hospital needed to complete the process of the review, which included a validation by OHFLAC/CMS. The spokesperson said that review took place on June 1. The email went on to say, “It would have been premature to comment before that, as the agency could have requested changes. Secondly, we need to inform our staff.” The spokesperson went to to say, “We really have not further statement and we are not interested in doing an on-camera interview.”

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