A former employee of a Saxonburg care facility was accused of endangering a care-dependent person after a woman died when she rolled off her bed and became trapped by a bed rail in 2019.

The state Office of Attorney General filed a felony charge Monday, April 22, against Sandra J. Wilbert, 60, of Fenelton, after an investigation was conducted into the death of a resident on Sept. 5, 2019, at the former Elmcroft of Saxonburg care facility in Bella Court.

Documents showed Wilbert was providing incontinence care to the woman that day and left her with her pants around her knees. The woman was found dead hours later, wedged between the bed rail and the mattress with her knees on the floor, agents said.

Officials wrote that had the woman’s pants been on correctly, she may have been able to save herself from becoming stuck after rolling off the bed.

Wilbert was suspended during an investigation and was terminated in October 2019 for gross misconduct, according to the affidavit. She had worked at the facility for 13 years.

Agents said the woman had been a resident at Elmcroft since June 2015 and had limited mobility and needed help getting dressed as well as care for incontinence.

The woman fell nine times while she was a resident, and four of those times were from her bed, agents said.

According to documents, the woman’s bed alarm was to be active at all times and her bed had two assistance or “halo” bars and was surrounded by fall pads.

On Sept. 4, 2015, agents said Wilbert was working the overnight shift on the hall where the woman lived. At 4:15 a.m. that night, Wilbert provided incontinence care to the woman, and changed her from a nightgown into a shirt and pants.

Wilbert later said she left the woman’s pants down around her lower legs so she would not soil them, agents said, and left the woman sleeping in the middle of the bed.

When she returned to the woman’s room around 6 a.m., the woman was found almost kneeling on the floor, with her head wedged against the halo bar and her face down toward her mattress, agents said.

The affidavit noted the woman’s cause of death as respiratory arrest.

Documents showed a supervisor and other medical professionals were interviewed about the incident and had difficulty discerning how the woman’s death occurred.

Nurses were unable to free the woman from the position they found her in until they moved the mattress completely, documents showed.

Agents said the practice of leaving a resident’s pants down was a fall hazard.

Family members were notified that morning that the woman was found dead. Documents showed the family declined an autopsy as they assumed the woman’s death was due to natural causes.

Agents said a family member then received a call from an anonymous employee of Elmcroft who encouraged them to have an autopsy performed on the woman as they did not believe her death was natural, and explained how she was found.

The family was unable to have an autopsy performed as the woman had already been embalmed by the funeral home when the request was made, agents said.

Agents said they interviewed Wilbert in August 2021 about the woman’s death. When they asked to speak about her previous employment at Elmcroft, agents indicated Wilbert said, “All I did was change the lady.”

Documents showed Wilbert disclosed she thought the woman suffocated.

Agents concluded the “failure to pull up (the woman’s) pants caused (her) legs to become entangled and her head to become trapped in the halo enabler bar.”

Agents said a search of records at Elmcroft showed Wilbert was coached three times for not responding to facility alarms in a timely manner.

Wilbert’s preliminary hearing before district court Judge Jack Ripper is scheduled May 21.