Nursing Home Abuse Lawyer Blog

Ninety-four year old nursing home resident Lester Pendergraft was charged with rape by instrumentation in Oklahoma County District Court on February 26, 2009. He is accused of a September 2008 sexual assault on a sixty-seven year old female resident at Grace Living Center in Edmond, Oklahoma.

Two facilitiy aides caught Mr. Pendergraft in the room of the female resident and stopped the assault. The woman was shaking and crying and was aware of the assault. However, the incident was not reported to police or family members for two hours. By then, the woman had been bathed and her clothing put in the laundry. In a written statement, Grace Living Center officials said, "Grace Living Center Edmond takes the responsibility to protect all residents seriously. We discovered the incident and immediately took steps to provide for the safety and care of the residents; we reported the matter to the health department and police." Police, however, reportedly told health officials that the nursing home facility handled the situation quite poorly. The facility Administrator told police that he thought "the situation was being blown out of proportion".

The state Health Department investigated the facility and cited the facility for six federal violations.

The woman's daughter contacted Wes Bledsoe of A Perfect Cause for support. Mr. Bledsoe does not wish to see Mr. Pendergraft sent to prison if he's found guilty, but, rather, believes a conviction would serve as an alert to keep Mr. Pendergraft from being left alone with other vulnerable nursing home residents in the future.

The Terry Law Firm is experienced in handling cases of nursing home sexual abuse. Please contact us at 1 (888) 317-2525 or visit us at www.nursinghomejustice.com.

Cheatum Myers, an 88 year old resident of NHC - McMinnville, died at the facility after allegedly being neglected. His family sued NHC for negligence, medical malpractice, and wrongful death. The plaintiffs sought compensatory and punitive damages for injuries sustained by Mr. Myers during his stay at the facility, including pressure ulcers, falls, bruises and abrasions, compression fractures of the spine, left hip fracture, urinary tract infections, weight loss, conjunctivitis and poor hygiene, as well as his death. The case was tried and ultimately resulted in a plaintiff's verdict for $34 million. NHC appealed the verdict.

A state appellate court has granted a retrial for punitive damages and has upheld most of a $4.1 million compensatory damage award. The Appeals Court determined that a trial judge erred in his decision to throw out almost all of an original $29.8 million punitive damage award, reducing the amount to $163,000.

NHC spokesman Gerald Coggin said, "NHC respectfully disagrees with the court's decision and we plan further appeals."

Theresa Smith

Theresa Smith, a former nursing assistant, pled guilty to stealing medication from nursing homes on Thursday, February 26, 2009, after initially denying all allegations. She was sentenced to six months in jail, three years' probation, and must undergo drug counseling.

Smith was arrested in the fall of 2008 after posing as an employee of Marysville Nursing Home and stealing Fentanyl pain patches from patients. Surveillance footage proved she was present at the facility. She has also been identified as a person of interest in a similar case at Laurelhurst Village Nursing Home in Portland, Oregon.

Anaheim Crest Nursing Center has been fined $75,000 in the death of an elderly resident.

According to state investigation documents, the resident, who suffered from dementia, had two choking incidents on September 9, 2008, the night of his death. In the first incident, the resident was given the incorrect diet, although it was known that he had a history of swallowing problems and was only to be given pureed foods. In the second incident, which occurred later that evening, he was left near a food cart, grabbed a sandwich, and began eating. He began choking and died within an hour.

State documents show that facility staff did not attempt to clear his throat, check him for aspiration, or provide emergency treatment. In fact, it was initially claimed that the resident died from a heart attack. The facility did not disclose that the resident actually choked to death on a tuna sandwich. It took three months before the truth came out and that only after the coroner revealed that the resident choked to death. According to the attorney for the facility, the facility held a second investigation after the autopsy and only then concluded that the man had grabbed a sandwich from a food tray.

This facility has not been without problems. In 2003, the facility was accused of giving unnecessary drugs to eight patients. The facility was also warned in the early 2000's for having unsecured or improperly secured doors, not keeping food within sanitary conditions, and failing to have a Korean speaker, although two-thirds of its clients spoke only Korean.

The Terry Law Firm is experienced in handling cases of nursing home abuse and neglect. Please contact us at 1 (888) 317-2525 or visit us at www.nursinghomejustice.com

Use of psychotropic drugs, also known as anti-psychotic drugs, in nursing homes to manage patients is becoming increasingly problematic. Dr. Kathryn Locatell, a geriatric physician who specializes in forensic investigation of elder abuse, recently assisted in the investigation of the Kern Valley Healthcare District's skilled nursing facility, is concerned that drugs that were intended to treat severe psychotic disorders are now being used on our loved ones in nursing homes to "control" them. Specifically, the drugs Zyprexa, Resperidol, and Seroquel, which are usually used to treat schizophrenia, are NOW being prescribed for nursing home residents to treat behavioral issues. Dr. Locatell said, "Doctors are just giving it out like candy and nurses are administering it without any knowledge of what to look out for. And they're being prescribed for behavioral problems - things like 'resisting care'. It's like they're being drugged to quell the behavior instead of someone investigating why the behaviors are happening and coming up with a more human approach. It really does boil down to what some believe is convenience."

The side effects of three drugs - Zyprexa, Resperidol, and Seroquel - are so severe on the elderly that they carry the U.S. Food and Drug Administration's (FDA) "black box" warning label. The "black box" label is the FDA's strongest designation for medications that could have life-threatening side effects, such as sudden death in elderly patients. These drugs stay in the elderly body longer and high doses for an extended period of time can cause multiple complications and side effects, such as constipation, risk of falling, and difficulty swallowing, which could lead to dehydration and weight loss.

National statistics show that approximately fifty percent of nursing home residents are on some type of psychotropic medication. Approximately thirty percent of that number are on a type of psychotropic drug. If your loved one is on a psychotropic drug, you should question its use.

Typical Questions to Ask

What medications is my loved one on?

What are you treating with this drug?

How will this drug improve my loved one's condition?

How often will this drug be administered and for how long a period?

What are the side effects? Is my loved one experiencing any side effects?

How will you monitor those side effects?

What other approaches can be used to treat my loved one? Has anything else been considered? Why are drugs the treatment approach?

If you have difficulty in obtaining answers to these simple questions, immediately demand a meeting with the Director of Nursing or the facility pharmacist. In this meeting, ask to review your loved one's care plan.

The Terry Law Firm is experienced in handling cases of nursing home abuse and neglect. Please contact us at 1 (888) 317-2525 or visit us at www.nursinghomejustice.com.

Dr. Hoshang Pormir, staff physician

Betty Dennison's mother in law, Beulah Dennison, died on January 21, 2007. She was only at Kern Valley Healthcare District's skilled nursing facility for less than three months. Several days before her death, Mrs. Dennison was told by a nurse that her mother-in-law was drugged to keep her quiet and cooperative.

Norma Lee Cudahey entered Kern Valley's skilled nursing facility in March 2006 for a knee surgery recovery. She died in November 2006 from a stroke. Her daughter, Patti McGarvey, does not know if her mother was given unprescribed drugs but worries that it could have happened. Ms. McGarvey said, "My mom had knee surgery and was supposed to come home. She had a sound mind. The next thing I know, she's practically in a coma."

Families with loved ones at Kern Valley's skilled nursing facility are agonizing over whether or not their loved ones were mistreated at the hands of trusted facility staff members. The druggings allegedly occurred between August 2006 and January 2007 and was done to residents who were argumentative, loud, or otherwise disruptive.

The California Attorney General's Office has filed a complaint alleging that three facility staff members: Gwen Hughes - Director of Nursing, Debbi Hayes - Pharmacist, and Dr. Hoshang Pormir - staff physician, drugged at least 22 patients, resulting in three deaths. Other family members have contacted the Attorney General's Office with their concerns over loved ones and if more complaints are substantiated, they will be added to the pending case.

Tish Orr was a registered nurse at the Kern Valley facility for 25 years and suffered a mental breakdown over what happened to the residents. Orr said, "I went to (Hughes) about people being lethargic because of the medications they were given and her response to me was, 'This conversation is at an end. You may leave now.' " Orr went higher with her concerns, only to be brushed off or, if the complaint got back to Hughes, threatened with termination or license revocation.

The Terry Law Firm is experienced in handling cases of nursing home abuse and neglect. Please contact us at 1 (888) 317-2525 or visit us at www.nursinghomejustice.com

Gwen Hughes, former Director of Nursing at Kern Valley Hospital's nursing home facility in Lake Isabella, California

We discussed this tragic situation in our previous blog. Three nursing home employees, Gwen Hughes, former Director of Nursing, Debbi Hayes, former pharmacist, and Dr. Hoshang Pormir, current staff physician, allegedly forcibly gave psychotropic drugs to 22 residents who suffered from Alzheimer's or other dementia-related illnesses. Hughes allegedly ordered the medications given to patients who argued with her, made noise, or were otherwise disruptive. Three residents died.

Hughes, Hayes, and Pormir pled not guilty on February 20, 2009 to charges that they forcibly drugged residents for convenience.

James Ritchea was injured on approximately May 22, 2002, when he fell from a ladder purchased from a local retailer. The Centers for Medicare and Medicaid (CMS) paid $22,549.67 in Medicare claims submitted on behalf of Mr. Ritchea for medical services rendered.

Mr. Ritchea obtained attorney Paul Harris to represent him in a legal proceeding against the ladder retailer alleging that the retailer was liable for Mr. Ritchea's injuries. The legal proceeding was settled in July 2005 and, as part of the settlement, Mr. Ritchea and his attorney received a payment of $25,000.

Mr. Ritchea's attorney forwarded CMS settlement information, including attorney's fees and costs. CMS calculated its lien amount, which was approximately $10,253.59. CMS allegedly was not paid its lien amount within the statutorily-required sixty (60) day time period and is now asserting a claim that it is entitled to its calculated share of the settlement plus interest and that it will not pay its full share of attorney's fees and costs. The total payment CMS is demanding is $11,367.78.

The federal government filed a complaint against Mr. Ritchea's attorney for declaratory judgment and money damages owed to CMS in the United States District Court for the Northern District of West Virginia. Defendant Harris filed a motion to dismiss but failed to file a specific response to the government's allegations. The District Court denied Harris' motion to dismiss on November 13, 2008.

In its opinion, the District Court in Harris stated that "Section 1395y (b) (2) (B) (ii) of the Social Security Act, commonly known as the Medicare Secondary Payer Statute ("MSPS"), states, in pertinent part, that when Medicare makes a conditional payment for medical services received as a result of an injury caused by another party, the government has a right of recovery for the conditional payment amount against any entity responsible for making the primary payment". The Court continued, saying that according to federal regulation 42 C.F.R. Section 411.24 (g), to recover payment, the government may "bring an action against any or all entities that are or were required or responsible...to make payment with respect to the same item or service...under a primary plan." 42 U.S.C. Section 1395y (b) (2) (B) (iii). CMS has a right of action to recover its payments from any entity, including a beneficiary provider, supplier, physician, attorney, State agency, or private insurer that has received a primary payment.

This case is a reminder that repayment of Medicare liens is required by the federal government. Failure to comply could place the attorney in the position of being held personally responsible.

Tamara Smith

We discussed nursing home identity thieves in our previous blog. Cousins Tamara Smith and Teresa Robbins reportedly stole the identities of 43 people, approximately half of whom were residents of Tara Nursing Home in Thunderbolt, Georgia. The cousins faced approximately 101 charges ranging from identity theft to fraud. Unfortunately, a loophole in the law will allow 26 of those charges to be dropped. Georgia law identifies an elder person as a person 65 years of age or older that is not a resident of a long term care facility. Therefore, 26 charges must be dropped. Captain James Pierce of the Thunderbolt Police Department intends to go through each date the perpetrators used someone's personal information either to order credit cards or purchase cell phones and determine whether or not that victim was a resident of a nursing home. Seventy-five charges will remain against the two for using the victim's personal information to purchase computers, cell phones, and open credit cards.

Jean Frantz Louisme and Aniamma Alex Philip were both recently cited by the state Board of Regents for their part in a November 27, 2007 incident at Rockland Psychiatric Center in New York.

Louisme was working as a registered nurse when another nurse advised him that she had determined that a patient had not received the prescribed drug Risperidone between November 7 and November 27, 2007. Louisme then made entries into the patient's chart showing that the drug had been administered when he did not know that the drug had actually been given. He admitted to practicing the profession of nursing with gross negligence, placed on professional probation for two years, and fined $750.

Philip was cited for practicing the profession of nursing fraudulently. She admitted that "she knowingly falsified the medication administration record of a patient so that it reflected the repeated administration of a medication when I knew it had not been administered". She, too, was placed on professional probation and fined $750.

Helmut Gutmann, 97, was a resident in the memory loss section of Friendship Village in Bloomington, Minnesota. He and his wife moved to Friendship Village approximately ten years ago and Helmut transferred to the memory loss section around two years ago. Mr. Gutmann fled from Nazi Germany and served as a captain in the U.S. Army's Chemical Warfare Service during World War II. He worked as a cancer research scientist for 40 years at the Minneapolis V.A. Hospital. He was also accomplished classical musician and played violin for the Bloomington Symphony Orchestra for 12 years.

Verne Gagne, 82, is a pro wrestling legend in Minnesota. He was a pro wrestler from 1949 to 1981 and won multiple NCAA wrestling titles for Minnesota. In 1960, he began "All Star Wrestling" on television. He was the sole owner of the American Wrestling Association (AWA) and helped launch the wrestling careers of Hulk Hogan and Jesse "The Body" Ventura. He, too, was a resident of the memory loss section at Friendship Village.

The men were roommates and both suffered from Alzheimer's-related dementia. However, on January 26, 2009, something went terribly wrong. Gagne and Gutmann apparently got into a fight, which was not their first altercation. Reportedly, Gagne threw Gutmann to the floor, breaking his hip and causing a head injury. No one was present when the altercation occurred and no one knows what precipitated it. Gutmann has no memory of the fight. Gutmann underwent surgery for his injuries and appeared to be doing fine and working on his physical therapy. However, during the week of February 8, 2009, Gutzmann "stopped taking any sustenance at all...He stopped eating and drinking" and died on February 14, 2009.

Mr. Gagne has been dismissed from the facility.

Arden Courts, a HCR ManorCare facility, has been slapped with the worst citation possible from the Cabinet for Health and Family Services. The "Type A" citation was issued for placing its residents at risk of death or injury. It carries a fine of up to $5,000.

Seven residents of Arden Courts, a Louisville, Kentucky personal care home that specializes in caring for individuals suffering from Alzheimer's disease, was cited for failing to provide proper care for seven residents. Those residents suffered from repeated falls, some of which resulted in lacerations and abrasions; one resident was unresponsive for several minutes following the fall. Two residents developed pressure ulcers that were not identified or treated and four experienced weight loss of 24 to 39 pounds in six to nine months. The state alleges that the residents affected needed more skilled care and assistance than available at the facility. Personal care facilities typically accept individuals who are able to manage most of their own activities of daily living, such as eating, bathing, and dressing. Facility staff is available to provide some assistance, but typically residents should be able to ambulate alone. All seven residents affected were noted to be "unable to manage their activties of daily living and required total assistance from the facility staff". One resident was unable to get out of bed without assistance, three could not move their own wheelchairs, and not one of them would have been able to exit the facility in an emergency.

The Terry Law Firm is experienced in handling cases of nursing home abuse and neglect. Please contact us at 1 (888) 317-2525 or visit us at www.nursinghomejustice.com.

We discussed the tragic death of Sara Wentworth in our previous blogs.

An investigation into Ms. Wentworth's tragic death has yielded some interesting information: a handwritten note hanging in the nurses' station reminding facility staff to always check the outside courtyard if a door security alarm sounds. Was this note always posted?

It is alleged that a 23 year old CNA turned offf the alarm, which is next to the posted note, and continued to watch television without thoroughly checking to see if anyone had exited the building. Ms. Wentworth wore an electronic ankle braclet that would sound an alarm if she exited any of the four doors - three of which lead to the courtyard. To thoroughly check, a facility staff member would have to walk down a 52 foot hallway, turn, and continue another 30 feet or so to look into the courtyard. Had someone followed procedure that night, Ms. Wentworth would have been seen and she might be alive today.

Authorities allege that staff panicked after finding Ms. Wentworth outside approximately one hour later and then conspired to make it look like she died naturally in her bed. Four female employees are being investigated for possible criminal charges relating to obstruction of jusice or criminal neglect. Charges could be filed as early as next week.

The Terry Law Firm is experienced in handling cases of nursing home abuse and neglect. Please contact us at 1 (888) 317-2525 or visit us at www.nursinghomejustice.com.

Sharon Haley, former nursing home administrator for Pinebrook Personal Care Center in Orwigsburg, Pennsylvania, allegedly took money from the nursing home and four residents. Haley allegedly wrote checks totaling nearly $9,000 from the nursing home trust fund and received money from residents but did not use the money as intended. Haley maintains she used the money for Pinebrook residents and to pay nursing home bills. She faces five counts of theft and remains free on bail pending court action.

We discussed the tragic death of Sarah Wentworth in a previous blog. If you will recall, Ms. Wentworth was found frozen to death on February 5, 2009 in the courtyard of The Arbor of Itasca after being outside for ninety minutes in frigid weather.

Her family continues to investigate the death of Ms. Wentworth. Family members hope to prove the facility staff's negligence in allowing Ms. Wentworth, who wore an ankle monitoring bracelet, to wander out of her room into the frigid weather outside. The ankle bracelet should have trigged an alarm when she exited the facility. The family hopes that the DuPage County State Attorney's investigation can also confirm an allegation that one employee at the facility "was watching television during a period of time when rounds were supposed to be made."

The family has filed a lawsuit alleging abuse and neglect on behalf of the facility. The incident continues to be investigated and measurements and photographs will be taken to document the line of sight from the nursing station to Ms. Wentworth's door and a door leading to the courtyard.

The Terry Law Firm is experienced in handling cases of nursing home abuse and neglect. Please contact us at 1 (888) 317-2525 or visit us at www.nursinghomejustice.com.

We discussed the abuse of Thelma Bryant in our previous blog. If you will recall, five employees of the Glen Hazel facility, including nursing supervisor Mary Ann Bower, were arrested for the physical abuse of Thelma Bryant, an elderly Alzheimer's resident. Bower has been charged with harassment for throwing objects at Ms. Bryant and pouring water on her head. Three of her four nursing assistants, Shelly Keene, Karen Perry, and Shalaya Hatten, are accused of assaulting Ms. Bryant by elbowing her in the chest, punching her in the eye, stomping on her feet, and throwing whole oranges at her face. Charges against yet another nursing assistant, Danielle Taylor, were dropped for lack of evidence.

Mary Ann Bower was convicted of harassment on February 18, 2009 and fined $300. Bower, the night supervisor, did not stop the abuse or reprimand other involved nurses. Three other former nurses still face charges for striking Ms. Bryant.

Bower may still lose her nursing certification after a state investigation.

Emily Townsend, a resident of Kettle Brook Care Center in Connecticut, fell from her bed in January 2008 and was hospitalized. Over the next two months, Ms. Townsend, 80, fell at least one more time. Her final fall occurred on March 29, 2008 and resulted in a broken left hip. Sadly, Ms. Townsend died three days after falling and breaking her hip. Her death certificate listed the broken hip as the underlying cause of death due to partial intestinal failure from a cut off blood supply and removal of part of her colon.

During that time period, Kettle Brook Care Center was operating under an unpublicized consent order from the Connecticut Department of Public Health (DPH). The facility had been fined $25,000 and its license had been put on probation for two years after "findings which seriously jeopardized the health, safety, and welfare of patients and which have resulted in serious negative patient outcomes". Under the consent order, the facility would be allowed to accept new residents after hiring an independent physician as a medical consultant. In turn, the physician was to hire a independent nurse consultant. The consent order also set minimum staffing ratios for the facility and required the facility to comply with quality measures, such as "necessary supervision and assistance devices to prevent accidents".

Robert Townsend, Ms. Townsend's son, had repeatedly complained to the state health department about his mother's care. In fact, he alleged that facility staff removed her bed alarm, a personal alarm, and a walker from her room - all against her physician's orders. His complaint lodged the day after her death prompted an investigation that revealed eleven violations, including failures to "provide interventions to prevent falls after the removal of an alarm" and to "utilize an alarm mechanism in accordance with the physician's order and/or to provide an environment free from accidents".

Kettle Brook's Administrator, Jennifer Carnovale, stated, "We have no reason to believe there is a valid claim against Kettle Brook". She justified the consent order entered into with the Department of Public Health by stating, "In 2006, Kettle Brook was one of 29 nursing homes in Connecticut that entered into a consent order with DPH."

To his credit, Robert Townsend has not given up his fight to be heard. He has repeatedly complained to senators, the attorney general, the governor, a state representative, and a variety of state health department officials. He alleges that state health officials are "more concerned about the well-being of nursing homes than the residents they should be protecting". Although Ms. Townsend's death certificate states that her death was ultimately caused by her fall, DPH Commissioner J. Robert Galvin stated, "Although we did have findings related to care planning in the area of falls, we were not able to validate Mr. Townsend's allegation that his mother's death was due to her last fall."

Mr. Townsend intends to seek damages in connection with his mother's "wrongful death".

The Terry Law Firm has experience in handling cases of nursing home abuse and neglect. Please contact us at 1 (888) 317-2525 or visit us at www.nursinghomejustice.com.

Kern Hospital

Resident Opal Towery argued with the nursing director and was subsequently injected with anti-psychotic drugs and spent the ensuing week in a stupor.

Resident Louise Zimmerman was biting, hitting, and kicking others. She was pinned down by four staff members and injected with anti-psychotic drugs. She never regained full consciousness.

Other residents suffered serious side effects from anti-psychotic drug injections such as severe lethargy, weight loss, inability to eat or drink, drooling, and incoherence.

In a complaint filed by the California Attorney General's Office, it is alleged that a nursing director, pharmacist, and physician drugged at least 22 elderly nursing home residents with anti-psychotic drugs in an effort to control them between August 2006 and January 2007 at the skilled nursing facility contained within the Kern Valley Healthcare District. The drugging lead to the unfortunate deaths of three residents:

Fannie May Brinkley died on December 23, 2006 after being given Depakote, a mood disorder drug. She did not eat for six days and died after being rushed to the Emergency Room. Ms. Brinkley's family was never told she was being drugged.

Eddie Dolenc was given anti-psychotic medication that severely sedated him. He was unable to eat or drink and died one month after being admitted to the facility from dehydration or pneumonia.

Joseph Shepter went to the Emergency Room on January 14, 2007 for dehydration and died five hours later. He had been given three anti-psychotic drugs.

The situtation only came to light in January 2007 when an ombudsman filed a complaint after seeing Louise Zimmerman held down and forcibly injected.

The Department of Public Health immediately commenced an investigation and determined that residents were being given high doses of psychotropic drugs to control them for convenience. Hughes was immediately dismissed.

Three top level nursing home officials were arrested for their participation in "forcibly administering" psychotropic drugs for convenience rather than for medical use. Arrested were:

Debbi Hayes, 51, a former pharmacist at Valley Healthcare District;

Gwen Hughes, 55, a former Director of Nursing at Valley Healthcare District; and

Dr. Hoshang Pormir, 48, staff physician at Kern Valley Healthcare District, who was serving as the medical director of the skilled nursing facility.

Hughes and Hayes face eight felony charges of causing harm or death of an elder or dependent adult and two felony charges of assault with a deadly weapon through overmedication. Pormir faces eight felony charges of causing harm of death to an elder or dependent adult. If convicted, they face up to eleven years in prison.

HISTORY

Gwen Hughes assumed her position as Director of Nursing in September 2006 and allegedly ordered that all dementia and Alzheimer's patients be forcibly given high doses of psychotropic medications to make them docile and easier to handle. These medications were also given to any patients who argued with her, were noisy, or were disruptive. Two resisting residents were held down and forcibly injected. A third resident had the drugs sprinkled on her food.

Hughes allegedly directed Debbi Hayes to fill prescriptions for these medications. Hayes wrote and filled these prescriptions without doctor's orders.

Nurses objected and raised concerns about the drugging and Hughes threatened to fire them and have their licenses revoked. Several nurses left the facility and one nurse told investigators that she was so distraught over the situation that she was on the verge of a "nervous breakdown".

Dr. Hoshang Pormir approved the medications after they had been administered and did not examine his patients to determine if the medications were medically necessary.

Pharmacist Samuel Obair, II assisted with the investigation said the situation was "beyond appalling"... it was "the first time I have ever run into this severity where it affected so many individuals and was being done so blatantly".

A physical restraint is any device that inhibits a person's movement or access to their body, such as bedrails. Physical restraints were once widely used in nursing homes to "protect" elderly residents from harm, keep them in their chairs and from wandering the halls. It was a widespread belief that restraints made residents safer. Use of restraints can cause muscles to atrophy and residents can become socially withdrawn. Statistics show that there have been deaths from restraint use. In fact, the Terry Law Firm has handled several cases where residents have died from the improper use of restraints. Here, Elwin McKenzie and Nancy Durgan, two of our clients, talk about their mother, the nursing home they chose for her, and her death by asphyxiation after becoming entrapped between her mattress and the bedrail restraint.
The United States does not ban the use of restraints if there are documented medical reasons to do so. In fact, in 1987, Congress passed a law that granted nursing home residents the right to be free of restraints and bans their use for discipline or ease of care.

Today, fewer care facilities are using restraints. "Untie the Elderly" is a decades-long crusade to stop the use of restraints and is credited for having gotten the message out about the danger of restraints. That movement united patient advocates, nursing homes, government groups, and private foundations in the fight to free elderly people from restraints. In 1991, 21.1% of residents were restrained daily. In 2003, that number dropped to 8.5% and to 5.5% in 2007. Twenty-five states use restraints on 4% or fewer residents. Three states actually topped 10% in restraint use: Arkansas, California, and Oklahoma. Pennsylvania is one of the leaders of the no-restraint movement with a 2.8% restraint rate.

Restraint use can be lessened if nursing home facilities pad their floors to prevent falls or lessen fall severity. Better pain managment can reduce agitation and efforts to increase companionship or provide activities assist residents with dementia. Constant assessment is important also. Simply altering a medication that causes dizziness or offering physical therapy to increase strenght or improve balance can make all the difference. Providing residents with non-skid socks, non-slip chair seats, lowering beds, and providing beds with special lips helps too.

An eighty-six year old woman is currently living the wave of the future: high tech sensors. After being in the hospital multiple times for congestive heart failure, the woman thought the worst was behind her. Her caregivers knew better - through motion sensors. There are motion sensors strategically placed in the woman's toilet and shower areas and in doorways. Pneumatic sensor tubes were placed beneath her mattress and beneath her easy chair. The bed sensors were detecting restlessness throughout the night - a signal of possible medical problems. The sensors helped her caregivers to determine that she was suffering from bloating at night, which is a common ailment of congestive heart failure patients. Her doctor prescribed diuretics and made other medication adjustments and helped her to sleep soundly again.

Other sensors available are contained in "smart carpets" and in pill boxes that remind seniors to take their medications timely. In fact, the pill boxes can also alert caregivers who are out of town if the medications are not taken. There are also robotic pets to provide companionship. Additionally, researchers are currently working on a virtual-reality silhouette imaging system that would allow observation of posture, gait, and other movements. Silhouettes will provide an alternative to the more invasive video cameras.

The technological advances made in sensoring will enable our seniors to live on their own for a longer period of time.

People with Alzheimer's disease or dementia have a tendency to wander and, once a person is discovered to be missing, time is critical. One such example is the tragic story of John Tierney. In July 2008, Mr. Tierney and his dog wandered away. He was found in a field on July 13, 2008, several days after wandering away. His dog led rescuers to his body.

Genesee County Sheriff Robert Pickell and the Elder Abuse and Prevention Program have joined together in protecting Michigan's senior citizens suffering from Alzheimer's disease or dementia. With $9,000 in federal grants, 50 GPS devices were purchased. The devices weigh less than two and a half ounces and will clip to the elderly person's clothing. The devices are charged for six hours and can last five days on that power. A website provides caregivers the exact location of the wearer and police and paramedics can also utilize the system in an emergency.

Country View Nursing Home, one of two county run nursing facilities in Iowa, has been cited for failure to provide proper care for pressure sores to some residents and problems with the times medication was administered. The Iowa Department of Inspection and Appeals levied a $3,500 fine following the December 2008 inspection. A follow up inspection on January 23, 2009 found the facility to be in substantial compliance in correcting those issues but other problems were noted, including poor housekeeping, failure by staff to follow protocol in feeding some residents, cleaning those suffering from incontinence, and wheelchairs being in poor repair. The second visit led to a daily fine of $200 until the facility obtains compliance. Additionally, a recommendation has been made to The Centers for Medicare and Medicaid to deny new admission payments.

The facility Administrator, Jack Musker, said lack of training was a large part of the problem. Country View has been without a staff trainer for nearly one year. The facility is unable to fill many open positions and relies on temporary employment agencies to fill the gaps.

Lemon Grove Care & Rehabilitation Center was cited and slapped with an $80,000 state fine for failing to properly supervise a resident while smoking. The resident caught fire and later died. The citation, a "AA" citation, is the most severe citation that can be assessed under California state law.

No staff members were monitoring the three residents on March 31, 2008, while they sat and smoked in a gazebo, which was the facility's designed smoking area. The seventy-four year old resident involved sat on an electric scooter and was trying to pull a nylon jacket over her head to block the wind while she lit her cigarette. The jacket caught fire and subsequently caught her on fire, burning her head, chest, and arms. She died from her injuries ten days later at a hospital.

The deceased resident, who suffered from memory loss, had lived at the facility since July 2007. She was a daily smoker who needed reminders to smoke only in the designated areas. The investigative report said, "She was confused, had decreased safety awareness and was non-compliant with the facility's smoking policy and yet the facility did not provide preventative measures such as routine or random monitoring by staff to ensure the resident's safety." The woman's relatives told state investigators that nursing home officials ignored concerns about the lack of supervision.

After the accident, the facility changed its policy and currently requires a facility staff member to be present at the gazebo while residents are smoking.

Kofi Agana

Kofi Agana, a former aide at Sudbury Pines in Sudbury, Massachusetts, was arrested on February 11, 2009 and charged with sexual assault of a resident of Sudbury Pines Extended Care. Agana allegedly assaulted the resident between February 4 and February 6, 2009. He has been charged with two counts of indecent assault and battery on a disabled person older than 60 and one count of assault and battery on a disabled person older than 60.

Allegedly, Agana went to the room of a female resident, whose speech was greatly impaired by a stroke. He closed the door nearly all the way and rubbed the woman's breast. He then grabbed her arms and held them down while he touched her genitals. Another resident was in the room during the assault but was sleeping.

The sexual assault was discovered when the resident was observed acting strangely toward Agana as if trying to get away from him. The facility conducted an investigation and fired Agana. While the victim has trouble speaking, she is able to say yes and no and police determined what happened through questioning. The victim pointed to various areas of her body and indicated that Agana was involved. Another resident has alleged that Agana fondled her while transferring her from her bed to a wheelchair.

Agana is due back in court on March 16 for a pretrial conference.

We discussed the alarming situation at Whispering Pines Nursing Center in our previous blog. You might recall that we previously discussed this facility when resident Carol Crow was assaulted. On July 11, 2008, Carol Crow was found with two black eyes and covered with bruises on her face, neck, and shoulders. Nursing home staff told Mrs. Crow's family that she had fallen in her room, but Mrs. Crow told her family an entirely different story. Mrs. Crow reported that a man knocked her down, got on top of her, and beat her until she was unconscious. While Mrs. Crow does have early onset Alzheimer's disease, she was very clear about what happened to her.

That was just the beginning. Wes Bledsoe and A Perfect Cause, a nonprofit patient advocacy group, got involved. The group offered a $2,500 reward for information concerning the alleged assault of Carol Crow. The tips the group received led to a larger state investigation.

ALLEGATIONS

The ensuing state investigation uncovered multiple allegations:

- Allegations that an aide forced a patient into a shower with his clothing on;
- Multiple allegations that nursing home residents were assaulting each other;
- Allegations that abuse complaints were not properly investigated;
- Allegations that staff lacked training to deal with patients with mental health problems;
- Allegations that a social worker put patients at risk for contracting AIDS when failing to provide condoms to a sexually active HIV positive resident;
- Allegations that the Medical Director failed to ensure staff and residents were regularly tested for tuberculosis.

The investigation report was 370 pages and found 16 federal and 12 state deficiencies. The citations ultimately caused the facility to lose its federal funding, forcing it to close. As a result of the closure, 128 residents will have to relocate and 140 employees will lose their jobs.

Wes Bledsoe said, "They knew what was going on. The current employees and the former employees that called us said that they had gone to management time and time again." Dorya Huser, long-term care division chief for the state health agency, said, "Whispering Pines has chronic problems, and they're unable to provide us with any credible evidence that they could clear them up. We're looking out for the best interest of the people that live there and deserve a better standard of care."

Mary Lowery, a former nurse aide at Attah County Nursing Center in Kosciusko, Mississippi, pled guilty on February 11, 2009 to five counts of petit larceny and must repay nearly $1,300 in fines and court costs. Reportedly, Lowery took personal items from the residents of Attah County Nursing Center, although the specifics of her theft have yet to be released.

Juan Tavares-Nunez, a former porter for Cliffside Nursing Home in New York, was convicted by a jury on February 11, 2009 of sexually molesting a 64 year old resident suffering from end-stage Alzheimer's disease. Tavares-Nunez was convicted of First Degree Criminal Sexual Act and endangering the welfare of an incompetent person. He will be sentenced on March 5, 2009 and will have to register as a sex offender and contribute his DNA to a DNA databank.

Tavares-Nunez was working a porter at the facility on the afternoon of July 27, 2007. He entered the room of a bedridden resident suffering from Alzheimer's and sexually assaulted her. The abuse was observed by Tavares-Nunez's supervisor, who reported it. Tavares-Nunez, a nine year employee, was immediately terminated.

"The defendant stands convicted of committing a particularly heinous crime against one of our most vulnerable citizens," district attorney Richard A. Brown said. "A nursing facility should always be viewed as a patient's home away from home. To force anyone to endure such a traumatic incident - especially one at such a fragile stage in their life - is beyond moral comprehension."

The Terry Law Firm is experienced in handling cases of nursing home sexual assault. Please contact us at 1 (888) 317-2525 or visit us at www.nursinghomejustice.com.

Colonial HealthCare was hit with a Class AA citation for inadequate care that led to the 2007 death of one of its residents.

The resident, who was 83 years old, fell and fractured several ribs. He died after suffering "excruciating, unrelieved pain" for 21 hours and then being given an "excessive dose" of a narcotic pain medication.

This is the third time since 2007 that the facility has been cited with such a penalty.

The Terry Law Firm is experienced in handling cases of nursing home abuse and neglect. Please contact us at 1 (888) 317-2525 or visit us at www.nursinghomejustice.com.

Richard Gerhardt was admitted to Laurel Canyon Nursing Home in Albuquerque, New Mexico on December 23, 2005, after suffering a broken femur. He was taken to Presbyterian Hospital on December 28, 2005 and died two days later. What happened in five days?

Mr. Gerhardt was allowed to lie on a bedpan for more than twenty-four hours on Christmas Day 2005. He laid on the bedpan so long that a horseshoe shape was seen on his posterior. The bedpan was on his back so long that it caused lesions that led to sepsis.

A state investigation revealed that the facility was "seriously" understaffed on Christmas Day. The lack of staffing led to the failure of the facility's safety checks and patient care required by the facility's own policies. Laurel Canyon faced charges of abuse of a resident resulting in substantial pain or incapacitation and neglect.

The case was prosecuted by the New Mexico Attorney General's Office as a Medicaid fraud on the premise that the facility received payment for services not rendered to Gerhardt. As the facility was found guilty and corporations cannot be incarcerated, the Judge will determine the facility's fine at sentencing.

Arden Hills Nursing Home is fighting state allegations of maltreatment after an elderly resident died after injuring her neck.

The resident suffered a broken neck on April 17, 2008. She initially complained of pain and a severe headache. The next day, she was "screaming in pain" when she moved her neck. On April 19, a staff member found a bump on the woman's head and she was sent to the hospital. A physician found a significant fracture to the cervical spine at C2, near the base of her skull. This type of injury suggests some type of fall or trauma earlier in the week and a physician suggested that the injury is usually related to a hyperextension of the neck. A neurosurgeon consulted for the state investigation said that the injury, also known as hangman's fracture because of its severity, couldn't have happened without experiencing trauma. Her family opted against surgery and the woman died on April 29, 2008.

The facility's campus director called the woman's injury and subsequent death an "unfortunate incident".

The Terry Law Firm is experienced in handling cases of nursing home abuse and neglect. Please contact us at 1 (888) 317-2525 or visit us at www.nursinghomejustice.com.

Spring Hills - Lake Mary nursing home in Lake Mary, Florida is under investigation after a 90 year old resident was found on the floor with blood around him. The resident, a hospice patient, fell out of his bed round 3:30 a.m. on February 9 and it was nearly two hours before facility staff found him. He was transported to a local hospital.

A facility spokesperson later said that it is the facility's policy to check on residents every two hours, but the resident was found within an hour and a half. "We actually exceeded the policies we currently have in place," said Jill Fredericksen, the facility's spokesperson. At this point, the facility has no plans to change their policy. Fredericksen said, "If we feel it necessary, we will review the policies but at this time it looks like we were there in time to help him."

This is not the first time this facility has had a problem with response time. Back in 2006, an 89 year old resident called 911 when she fell out of bed and could not get anyone to respond. Lake Mary police responded and could not get anyone to let them in because two workers were asleep. The ensuing investigation resulted in two workers' arrests for neglect and owners were ordered to make changes or shut down.

The Terry Law Firm has experience in handling cases of nursing home abuse and neglect. Please contact us at 1 (888) 317-2525 or visit us at www.nursinghomejustice.com.

We discussed the physical abuse of an elderly resident at Kane Regional Center's Glen Hazel facility in previous blogs. Originally, five employees of the Glen Hazel facility, including a nursing supervisor, were arrested for the physical abuse of Thelma Bryant, an elderly Alzheimer's resident. Mary Ann Bower, the facility nursing supervisor, has been charged with harassment for throwing objects at Ms. Bryant and pouring water on her head. She is currently awaiting her preliminary hearing. Three of her four nursing assistants, Shelly Keene, Karen Perry, and Shalaya Hatten, are accused of assaulting Ms. Bryant by elbowing her in the chest, punching her in the eye, stomping on her feet, and throwing whole oranges at her face. Keen, Perry, and Hatten were held at a preliminary hearing and will stand trial on the abuse charges. Charges against Danielle Taylor were dropped for lack of evidence.

Allegedly, one of the accused abusers, Shalaya Hatten, previously pled guilty to two harassment charges stemming from two separate incidents when she worked for Allegheny County. Hatten was charged with misdemeanor simple assault in 2003 and felony aggravated assault in 2005. She pled guilty to lesser harassment charges in both incidents. More information concerning the incidents was not readily available. Hatten is accused of elbowing and swearing at the Alzheimer's patient. According to one witness, she cursed at Ms. Bryant and then put her elbow into Ms. Bryant's chest and pushed hard for up to a minute. The witness alleges that this happened at least twice.

All have been fired.

Sarah Wentworth

Sarah Wentworth was eighty-nine years old and had suffered from dementia for more than ten years. Two years ago, when her family could no longer ensure her safety at home, they moved her to The Arbor of Itasca nursing home in Itasca, Illinois. They thought she would be safe there.

They were wrong. Ms. Wentworth wore an ankle monitor and used a walker. She could not get out of bed by herself. How did she get through two doors with alarms in the middle of the night and freeze to death in the middle of the nursing home courtyard? Police are investigating.

Her family is searching for answers. Her daughter, Pamela Kennedy, said "Her fear is to be alone and cold. And that's how she died."

The Illinois Department of Public Health website shows that the facility has had more than fourteen complaints filed against it in the last year.

The Terry Law Firm is experienced in handing cases of abuse and neglect. Please contact us at (888) 317-2525 or visit us at www.nursinghomejustice.com.

Berwyn Rehabilitation Center, formerly known as Pinnacle Health Care of Berwyn, is a 145 bed nursing home facility located in Chicago, Illinois. According to the new ratings system instituted by The Centers for Medicare and Medicaid, the facility is rated as a one-star facility, which indicates a "much below average facility".

According to inspections conducted by public health inspectors, the one-star rating was well deserved. A March 2008 inspection revealed 29 violations, which is twice as many as any other one-star facility in the area. The Director of Nursing hired in May 2008 said "This nursing home was really bad. Workers were punching in and doing nothing." The home has been under new management since Spring 2008 and the Director of Nursing acknowledged "The bad, bad employees we got rid of."

Of the eighty-eight residents at Berwyn Rehabilitation Center, most are unable to walk, are incontinent, and need constant care. One quarter of the residents cannot breathe without a ventilator. Sadly, most are poor and have no family to visit.

In March 2008, five state public inspectors conducted a surprise inspection on the facility. Unfortunately, the surprise was on the inspectors. First, they were greeted at the door with "an offensive urine odor" that remained throughout the day.

They entered a room where they found a 97 year old incontinent woman lying on her back in bed. Her privacy curtain was soiled and "feces was loose and completely dried on the sheet". The inspector noted a bed sore on both buttocks that was the size of a golf ball and her left heel was red and mushy. She had severe bruising on her left arm and both legs. When questioned about her bruising, one nurse and nurse aide told an inspector that they did not know how the bruises occurred. Another nurse told the inspector that the bruises were caused by a mechanical lift used to transport the resident to dialysis treatments. At dinner, the resident did not eat and told the inspector that she was in too much pain to eat.

The next day, the inspector visited the woman a second time and again found feces on her and her bed pad. She had been washed but not well. A nurse aide washed her again, but again, it was not done well. The aide also did not clean the woman's catheter tubing, which had been sitting in the feces. The resident "cried out in pain when the tubing was handled". The inspector noted that the resident did not eat at the next two meals and alerted the facility administrator. Her bedsores were worsening and she complained of pain and was lethargic. Four hours later, while undergoing dialysis, the resident's blood pressure dropped and she was unresponsive. She was taken to the hospital and admitted with pneumonia.

She was not the only resident suffering. A resident with Alzheimer's disease had a gangrenous left foot. That resident had "a large amount of loose fecal matter, which soiled the entire heel portion of her left foot dressing". When checking the resident later in the day, the inspector found the dressing still soiled and the resident "grimaced and cried in horrible pain" when a nurse changed the dressing and respositioned her foot.

Another resident had a bleeding bed sore. The facility's explanation for the lack of treatment was that the resident had refused treatment. Inspectors said that was no excuse not to address it.

Facility inspectors found that side rails were being used on the beds without any determination of whether or not the residents needed them. One resident had injured his leg after catching it in a side rail. Four months later, in July 2008, a morbidly obese resident was entrapped between the inflatable mattress and the side rails. A respiratory therapist found him and quickly deflated the mattress. He had turned blue and was transported to the emergency room, where he was pronounced dead. An autopsy revealed that he suffocated due to entrapment. Sadly, the resident's physician had ordered one-quarter length side rails for the bed to prevent falls. The rails had broken just prior to the man's death and could not be fixed, so the repairman replaced the broken rails with full side rails.

The facility was inspected again on January 25, 2009 in a surprise inspection. The results of the inspection are due to be released soon.

The Terry Law Firm is experienced in handling cases of nursing home abuse and neglect. Please contact us at 1 (888) 317-2525 or visit us at www.nursinghomejustice.com.

There are a variety of ways to check on nursing homes in Illinois to check on their performance.

The Centers for Medicare and Medicaid - The Centers for Medicare and Medicaid instituted a new ratings system in Fall 2008 that allows consumers to compare nursing homes and check out their ratings. Check and see the ratio of registered nurses versus residents. Consumers can locate this information at under "Nursing Home Staffing".

Illinois Department of Public Health - The Illinois Department of Public Health has a very helpful site for reviewing nursing home information. Consumers can locate nursing homes in Illinois, nursing home owners, nursing home inspection reports, and even nursing home violators.

All nursing homes are required to post their annual inspection at the facility. Consumers also have the right to review the facility's past complaint and inspection reports. Do not hesitate to ask to review those documents.

If your loved one is already in a long-term care facility and is receiving poor care, file a complaint with the Illinois Department of Public Health at 535 West Jefferson Street, Springfield, Illinois 62761 or contact them via telephone at (217) 782-4977.

Dorotha Gifford wandered outside on February 5, 2009. She walked to a gazebo on the nursing home grounds - her footsteps were visible in the deep snow. She was outside for approximately two hours, in frigid temperatures, dressed in just slacks, a shirt, and shoes.

Ms. Gifford was a resident of the Alzheimer and dementia unit at Heartland of Woodridge. It appears that she just wandered off. Temperatures that day ranged from a high of twenty-seven degrees to a overnight low of eight degrees. Nurses discovered she was missing during an hourly check and began an immediate search. The facility called police around 3:10 p.m., but it was too late. Ms. Gifford was found dead outside - just sixty yards from the facility.

The Ohio Department of Health is investigating the incident and expects that it will take two to four months to complete.

Michael Stuart Sende must serve twenty days in jail for injuring an elderly resident suffering from Alzheimer's disease while assisting him take a shower. The elderly man was taken to the hospital for a medical issue and found to have suspicious injuries. After an investigation, Sende was charged with criminal abuse of a vulnerable adult by a caregiver.

Sende entered an Alford plea in November 2007. An Alford plea acknowledges that evidence in the case could result in a conviction, but the defendant does not actually admit guilt.

In addition to the twenty days to be served in jail, Sende was also fined $3,000 and placed on two years probation.

The Terry Law Firm is experienced in handling cases of nursing home abuse and neglect. Please contact us at 1 (888) 317-2525 or visit us at www.nursinghomeabuse.com.

Last year, The Centers for Medicare and Medicaid instituted a new ratings system for nursing homes in an effort to educate the public on facilities they were considering utilizing for their loved ones. Unfortunately, there is no such rating system in place for assisted living facilities, which can be just as detrimental as skilled facilities.

Some states have instituted their own ratings systems for assisted living facilities, but in mnay states, the only way to obtain information about the facility is to file a Freedom of Information Act request with the state. Many advocate that a uniform rating system needs to be instituted for the general public to obtain information about assisted living facilities and to force assisted living facilities to be held accountable for substandard care.

Certainly, there are differences between assisted living facilities and nursing homes. Residents of assisted living facilities need assistance with a few activities of daily living, such as dressing, bathing, or taking medicine, but on the whole, they are often able to care for themselves.

One example of assisted living comes from South Carolina. Sandra Belaja became a resident of Palmetto Residential Care Facility in North Charleston, South Carolina after a hospitalization. She went to the facility for assistance in taking her medications. Previously, she lived on her own and was able to take care of herself. When she arrived at the facility, Ms. Belaja's heart was not even working at ten percent and she was suffering from congestive heart failure, lupus, and other health problems. She left the Palmetto Residential Care Facility due to poor living conditions. She alleges that residents often went without toilet paper and soap in the bathroom, which had two toilets for twelve people. She said when the heating broke, residents were kept warm by an oven. Ms. Belaja opted to move to the Value Place Hotel. There, hospice workers bring her oxygen and monitor her medicine.

Some states have instituted their own ratings systems for assisted living facilities, but in many states, the only way to obtain information about the facility is to file a Freedom of Information Act request with the state.

Bad things can happen in assisted living facilities just like in nursing homes. In short, a uniform rating system needs to be instituted for the general public to obtain information about assisted living facilities.

Steven Laroche, a former CNA at St. Joseph's Manor Nursing Home in Brockton, Massachusetts, pled guilty on February 2, 2009, to indecent assault and battery on an elderly person. He was sentenced to two years in jail, with a suspended sentence. He was ordered to serve two years probation, wear a GPS monitoring bracelet, and register as a sex offender. You will recall that Laroche, now 69, was responsible for the care of a 93 year old resident who suffered from Parkinson's disease and dementia. During the overnight shift on January 31 - February 1, 2006, another CNA entered the resident's room and observed Laroche sexually assaulting the resident. The CNA informed her charge nurse of what she observed and a physical examination of the resident revealed that he had been a victim of a sexual assault.

While Laroche has been punished for his crime against the elderly resident, the nursing home is not off the hook. The family of the elderly man filed a lawsuit in July 2006 seeking damages for breach of contract and malpractice. The nursing home had been fined by the state for failing to report the assault or notify a physician, social worker, or the victim's family. Another CNA notified the state of the assault and subsequently lost her job at the facility. At issue is whether the nursing home is responsible for the actions of its employees. The nursing home alleges it is not responsible for anything that deviates from normal care. The attorney representing the family in the civil lawsuit believes "the plea by the defendant yesterday is relevant". A trial date has not yet been set.

The Terry Law Firm is experienced in handling cases of nursing home sexual abuse and assault. Please contact us at 1 (888) 317-2525 or visit us at www.nursinghomejustice.com.

Ramil Panlaqui will be spending time in jail. The former caregiver at Atherton Healthcare pled no contest to three felony charges of financial elder abuse. Taking a deal offered by prosecutors, Panlaqui avoided a maximum ten year prison sentence on multiple felony counts, including residential burglary and elder abuse. He will spend six months in prison and faces three years' probation. He must also reimburse Wells Fargo and Bank of America for the stolen money.

Panlaqui stole the checkbooks of an 88 year old resident and a 75 year old resident and wrote multiple checks from one resident's account to the other resident's account. He then withdrew the money from the second account. In all, he stole approximately $4,000. Authorities found a third completed check in his possession after his arrest.

We discussed Glenwood Resource Center and its care problems in previous blog entries. Glenwood was recently fined $11,500 by the State of Iowa in connection with the death of a 26 year old resident in November 2008.

Timothy Alexander began suffering seizures on November 19, 2008, while eating dinner. After the seizures began, there were delays, errors, miscommunications, and problems with equipment that resulted in his death.

- Rather than activate the facility's emergency response system, a facility worker left the resident to alert a supervisor, who then called a nurse, who then called a different nurse who arrived seven minutes later to care for the resident. Both nurses told inspectors that they were slower than normal to respond because they thought the seizures were over.

- Mr. Alexander was examined at a hospital and then taken to an infirmary at Glenwood when he complained of a headache. He did not receive his regular dose of medication that evening, which consisted of seven medications, but the medications never made it to the infirmary. A facility worker explained to inspectors that she was "very busy" and didn't think about the chart.

- A Glenwood physician wrote an order allowing Mr. Alexander to return to his cottage where he lived at Glenwood - without ever examining Mr. Alexander. The doctor said he ordered regular neurological checks on Mr. Alexander, but there is no written order. The doctor told inspectors that the staff must have forgotten to write down that part of his order.

- A nurse initiated a plan for regular neurological checks for Mr. Alexander but another nurse halted the checks after initial examinations indicated that Mr. Alexander was doing well. The nurse did not check Mr. Alexander's breathing because she did not have the proper equipment with her.

- At his cottage, Mr. Alexander was to be checked every 15 minutes. A worker checked on him at 9:45 a.m. on the morning after his seizure found him in bed and his skin a bluish-gray. The worker began CPR, but 18 minutes passed before a "Code Blue" was initiated.

- Rather than calling 911, the worker who found Mr. Alexander first called Glenwood's switchboard and then called a supervisor and told the supervisor to call 911.

- Nurses were brought to the cottage. They tried to use a hand-held bag to help Mr. Alexander breathe, but the bag malfunctioned. They tried to use a second bag and it too malfunctioned. Mr. Alexander still had a faint pulse at that point.

- Mr. Alexander was taken to the hospital, where he was removed from life support after no sign of brain function. He had lived at Glenwood for five years.

Inspectors later found that the doctor's orders to check Mr. Alexander every 15 minutes were long-standing orders. One caregiver was completely unaware if an order existed and the other two thought the order was to check him every 30 minutes. Eight of 10 staff members could not properly describe a "Code Blue" procedure. Their knowledge of a "Code Blue" procedure conflicted with protocols.

Dr. Sohail Kahn was one of Mr. Alexander's physicians. Interestingly, Dr. Kahn, a neurologist, works at the facility on a three month rotation: he works at Glenwood for 90 days and then returns to Pakistan, where he is consulted via telephone for 90 days, and then returns to Glenwood for 90 days.

Care at Glenwood has been the source of scrutiny for some time. In fact, Governor Chet Culver has promised an independent review of the facility this year. Some interesting findings at Glenwood are:

- The death rate at Glenwood was higher in 2008 than any other time in the past five years.

- None of the facility's nine psychologists is licensed by the Iowa Board of Psychology and that makes them exempt from independent oversight. Eight of the psychologists are supervised by the ninth, who was given the job after state officials mistakenly believed that he did not need a license to meet Glenwood's qualifications for that position.

- Two recent medical directors at Glenwood were gynecologists and neither one were licensed to practice medicine in Iowa. Glenwood kept a third unlicensed physician on their payroll for three months last year.

- Last fall, Glenwood hired an administrator who lost his Nebraska teaching license after having sex with a 17 year old student.

Pamela Jo Morris pled guilty to mail fraud on February 2, 2009 in U.S. District Court. Morris, a former nursing home employee, stole personal information from a patient and applied for a credit card. Once the card was received, Morris charged approximately $2,700 to the account. She faces a maximum of twenty years in prison and a $250,000 fine at her May 2009 sentencing.

We discussed Henrietta Sprual and her outrageous abuse of a defenseless nursing home resident in our previous blog.

In an amazing lack of regard for her victim and our court system, Henrietta Sprual has skipped her court sentencing again. In fact, this is the second time in a month that she has done so. Judge Richard J. Hodgson issued a bench warrant for her arrest - the second warrant in a month.

Spraul is facing sentencing for her abuse of an 87 year old resident at Arden Court on December 7 and 8, 2007. Spraul repeatedly hit the man with a belt, causing multiple bruises on his elbow, shoulder, knee, and thigh. Her victim suffered from advanced Alzheimer's disease. Sprual pled guilty in October 2008 to charges of simple assault, recklessly endangering another person, possession of an instrument of crime, and making false statements to authorities. She was originally due in Court on January 7, 2009 and skipped that hearing.

She faces a maximum of seven years in prison.

Yvonne Winslow

Yvonnne Winslow, a former nursing home worker at Savannah Specialty Care Center in Savannah, Georgia, sits in jail facing six felony charges, including elderly abuse. Winslow alleged took a debit card belonging to Ron and Charlotte Miller from their room and used it at area businesses. She has admitted her involvement to investigating authorities.

Sister Mary Daniel died on September 7, 2008 from injuries she sustained on August 31, 2008, when a 200 pound, 7 foot high and 2 foot wide freestanding closet unit fell on her. The closet was unsecured. There were two other incidents involving freestanding closets falling prior to the closet that fell onto Sister Mary Daniel. We discussed the circumstances surrounding Sister Mary Daniel's death in our previous blog.

Now, to add insult to injury (and death), Rockland County has filed a notice of claim to seek money from the Sister Mary Daniel's estate. The County, which runs Summit Park Nursing Care Center, is seeking more than $200,000 for her care before and after the accident.