On a cold and rainy New Year's Eve, a retired Philadelphia police officer rode an elevator to the first floor and walked out the door of the Delaware Valley Veterans Home.
Harold Chapman, 75, diagnosed with dementia and work-related brain damage, wore only pajamas when he stepped past a manned security desk at 5:30 p.m. Dec. 31, 2007, and into the winter cold.
Two hours later, a staffer reported that she could not find Chapman, a Korean War veteran, in his room or anywhere else. Neither could searchers in a police helicopter.
Ten hours passed before Chapman's lifeless body was found a few yards from the state-run nursing home.
"If he were any closer, they would have tripped over him," his widow, Barbara Chapman, said in a recent interview.
Chapman's death prompted new procedures at the Philadelphia hospital to prevent a recurrence, said Jeffrey Backer, an official of the state Department of Military and Veterans Affairs. He said that a warning system triggers an alarm if designated patients try to leave.
The extent of such incidents in the state veterans-home system could not be determined. Backer said that he could not provide data on other incidents.
The Pittsburgh Tribune-Review has been investigating state veterans' homes and has found serious deficiencies at two of them, in Hollidaysburg and Scranton. The U.S. Department of Health and Human Services rated those facilities below average in meeting inspection requirements, giving them the lowest possible ranking: one star out of five, while other homes in the system fared better.
The 1,632-bed state veterans health system, dating to the Civil War era, costs $165 million a year to operate. It is separate from the federal Veterans Affairs. The state facilities include nursing-home beds, personal care facilities and locked dementia units, where many of the serious violations occurred.
In Philadelphia, details about Chapman's death emerged in a lawsuit his daughters filed against the state. Evidence produced for the lawsuit includes surveillance tapes of the former policeman leaving the home.
"It was New Year's Eve, and everyone was getting ready for a party. He walked right by them," said Barbara Chapman, who viewed the tape. "He couldn't find his way back, and got lost. They told me it was painless, but I later found out it can be a very horrible death."
Citing the litigation, state officials declined to discuss the Chapman case, including employee suspensions and other disciplinary actions.
Records from the Delaware Valley Veterans Home show that there were multiple failures by staffers, first by not monitoring Chapman's movements and, after he was belatedly discovered missing, by failing to immediately follow established emergency procedures.
Staffers didn't notify the home's commander until after 9 p.m., more than three hours after Chapman disappeared. They didn't call police until 9:15 p.m.
Surveillance tapes show that Chapman left his restricted area by riding the elevator with an employee who was not authorized to be in the building at that time.
State health inspectors later cited the home for multiple violations of state and federal laws and regulations, and several staffers were either reprimanded or suspended.
According to the inspection report, staffers failed "to take timely action resulting in actual harm and death to the resident."
One staffer, one of the last to be seen with Chapman, abruptly quit his job when told he would be questioned. Called "a person of interest" by investigators, the aide later was discovered to have a criminal record for stalking.
The Philadelphia Medical Examiner's Office concluded that Chapman died of hypothermia and that the incident was accidental.
Another fatal incident at the Philadelphia home happened when two residents got into a shoving match in a lunch line and one of them died. The surviving patient was acquitted of involuntary manslaughter charges in June.