A Legal Matter

Litigators and legislators play chicken-or-egg with nursing home issues

Billy Raley, 59, died in March 2000. Brandon Peters, his family's lawyer, says the staff at Glendale Care Center gave him a lethal dose of morphine. The lawsuit was dismissed in September because of an error, Peters says, but will be re-filed.

James Bryley, a 28-year-old quadriplegic, died in June 2000 because of bed sores, according to an autopsy report. The nursing home argued that he had refused treatment, but that didn't pass muster with Betty June Scira, a Tucson nurse who visited him during his final days at Glendale Care Center and found him emaciated and dirty.

"The condition that Mr. Bryley was in allowed no dignity and respect, even of a dying person, and I've seen hospice patients many times," Scira said in a deposition. "I've just never seen such a loss of dignity in my life. Never. It was like a concentration camp thing you would see." Life Care Centers settled a lawsuit brought by Bryley's mother.

Marilyn Mindham suffered from multiple sclerosis and a genetic disease that caused her bones to fracture easily. She developed a pressure sore so massive that a surgeon had to remove metal hardware that held her bones together so he could cut away the mess. She died from sepsis in July 2000 at age 52. Life Care Centers settled the case, which was brought by McGroder and Wright.

Ruth Mae Washington, who died the day after the state ruled that Glendale Care Center hadn't provided proper care to Johnson, was admitted to the nursing home three days before Johnson. Like Johnson, she ended up with a bedsore on her backside that went down to the bone and required surgery. But that isn't what killed her, her family says. Records from the nursing home and its pharmacy showed that Johnson had never been given a drug prescribed to heal a stomach ulcer. She died from complications from peritonitis after the ulcer burst, her family alleges. Two doctors, including the surgeon who repaired the ulcer, were prepared to testify that the ulcer burst as long as four days before she was taken to St. Joseph's Hospital at her family's insistence. She arrived at the emergency room with a temperature of 104.4 and a pulse rate of 101 beats per minute; in Washington's chart, a Glendale Care Center nurse wrote that she "left facility in no acute distress."

When Washington left the nursing home, she weighed 119 pounds, 50 pounds less than she'd weighed a month earlier. Yet the nursing home didn't summon a dietitian, according to her family's lawsuit filed by McGroder and Wright. The company settled the case. The state found no violations.

In the Johnson lawsuit, two former Glendale Care Center administrators have testified that the nursing home was in crisis while these people were dying. One used the word "meltdown"; the other said care systems were "massively broken."

The state's response to problems surprised even the administrators. In a July 2001 internal memo, the home's administrators said they expected state inspectors to issue 10 citations after an investigation into allegations of untreated pressure sores. The home ended up with three violations, none deemed serious enough to have harmed residents.

Life Care Centers did not respond to an interview request made through its attorney.

Problems continued at Glendale Care Center after the deaths, with no punishment from regulators.

In June 2003, inspectors found that the home didn't promptly send a resident to the emergency room after he broke his wrist and bumped his head after falling from his wheelchair. A doctor told the staff to send him to the hospital if his condition worsened. Normally a "happy-go-lucky" fellow, according to his roommate, the resident stayed in bed, refused meals, mumbled and appeared confused, according to the roommate and a staff member who said he "never made sense" and was "totally different" after the fall. He kept trying to remove the bandage from his fractured wrist. He went nearly two hours at one point without having his vital signs checked and more than three hours immediately after the fall without the staff checking for signs of neurological impairment. What checks were done showed that he was running a fever and had elevated blood pressure.

Three days after the fall, a nurse found him unconscious when she went to his room to give him medication. Instead of sending him to the emergency room as the doctor had ordered, the home telephoned an on-call medical provider. When the resident finally made it to the hospital, a CT scan showed bleeding in his brain. He died two days later. State inspectors issued three citations but determined none of the violations had harmed the resident, so there were no sanctions.

The same day the resident was found unconscious, inspectors paid an unannounced visit to investigate a complaint that dialysis patients weren't being given prescribed medication, including antidepressants, painkillers, insulin and drugs to treat hypertension and renal disease. The inspection report shows a half-dozen residents weren't getting all of their drugs; one resident missed 163 doses of various medications in a three-month period. Instead of writing it up as a deficiency in pharmacy services, as the state had done two years earlier after finding a dozen Glendale residents hadn't received their prescriptions, inspectors concluded the home had failed to "give each resident care and services to get or keep the highest quality of life possible."

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