By Amy Silverman
By Olivia LaVecchia
By Monica Alonzo and Stephen Lemons
By Chris Parker
By Michael Lacey
By Weston Phippen
In February 2003, the state found that Suncrest Healthcare Center in Phoenix near South 24th Street and East Southern Avenue hadn't given morphine to a woman before such simple tasks as taking a shower, as ordered by her physician. Her pain was obvious when the staff cleaned a bedsore: "During the hour-long treatment, the resident, who is non-verbal, occasionally widened her eyes and batted and waved her left hand in the air toward the nurse, clenched the side rail with her left hand, displayed facial grimacing, including tightly closed eyes, and her body was shaking." The state inspector who wrote this account found that the woman hadn't gotten any pre-treatment painkillers for at least two weeks. The state found a total of 15 violations, including a woman who went three days without a shower and a woman who sat naked from the waist up in a hallway for several hours, in full view of staff, visitors and other residents. Rooms and halls reeked of urine, and floors, walls and privacy curtains were stained with feces.
In February 2003, the state found that the staff at Bryans Extended Care Center in Phoenix, which has since been acquired by a new owner, didn't change the bandage over a sore on a resident's heel for 11 days. The resident developed gangrene and had his leg amputated below the knee.
In September 2003, investigators determined a resident fell out of bed at Phoenix Mountain Nursing Center in northeast Phoenix after the home used improper bed rails. The resident suffered a fractured hip.
In September 2003, Heather Glen Care Center in Glendale was cited for failure to get dental care for a resident with loose and broken teeth. He cried out when his teeth were touched, and jerked away when a staff member approached with a toothbrush.
In February of this year, the state found that Highland Manor Health and Rehab in Phoenix hadn't given enough water to a resident who suffered dehydration so serious he was sent to a hospital.
In April, the state found that Life Care Center of Scottsdale hadn't properly treated or assessed pressure sores in four residents. The home also hadn't followed doctors' orders in tracking hydration in two residents, one of whom developed a urinary tract infection. And the home hadn't used the proper bed rails for a resident who fell out of bed and broke her hip.
In yet another case that resulted in no fines, Eugenia Zarembski fell and broke her right leg in the spring of 2003. Her doctor told the staffers at Plaza Del Rio, a Peoria nursing home, to keep a leg brace in place at all times. They took him literally.
Three weeks passed before anyone looked under the brace, even though the staff knew Zarembski was at high risk for developing pressure sores and was supposed to be checked weekly from head to foot. By the time a nurse found the sore on Zarembski's right calf, it had turned black. She had a cluster of less serious sores around her knee.
Three days after the sores were found, Zarembski's family took her out of Plaza Del Rio and sent her to a nursing home in Modesto, California, where the staff noted she was "dirty and unkempt." She smelled of old urine, according to admission notes written the same day she left Plaza Del Rio. Dirt was caked between her toes. "Teeth dirty, unbrushed," her new caretakers noted. Her right heel was black from another sore; her left heel was red and mushy.
Zarembski died on October 4, 2003, from pneumonia. She was 94. Malnutrition, pressure ulcers and orthopedic trauma were contributing factors, according to an autopsy report. In a lawsuit filed in September, Zarembski's niece says the nursing home and the physician who ordered the leg brace are responsible for her aunt's death.
Zarembski wasn't the only one who suffered at Plaza Del Rio. While investigating her case, a state inspector found that three other residents had suffered harm because their pressure sores weren't properly treated. One woman hadn't had the bandage over her sore changed for two weeks; her daughter told the inspector that the staffers never repositioned her mother to help the sore heal. The staffers certainly seemed busy: In full view of the inspector, a nurse's assistant summoned via a call light to help change the woman's soiled undergarments bellowed, "I told them don't put me down for no lights 'cause there's no time for lights here."
Because of "lack of sufficient evidence," inspectors couldn't substantiate an allegation that Plaza Del Rio hadn't given Zarembski enough food. The complaint report shows the state relied on the home's records, which showed Zarembski gained two pounds during her three weeks at Plaza Del Rio and weighed 91 pounds when she was sent to California. There's no evidence the state checked with the Modesto home that admitted her the same day she left Plaza Del Rio.
According to the Modesto home, Zarembski weighed 75 pounds when she arrived, 16 pounds less than claimed by Plaza Del Rio.
Plaza Del Rio wasn't fined or otherwise punished. In the world of nursing home enforcement, a bedsore here and there doesn't count. Eugenia Zarembski and these other folks were gimmes in a system built on second chances.