A nursing home didn’t have a legally required call system in a communal bathroom when a resident died in March, according to an investigation by the Missouri Department of Health and Senior Services.  The Columbia Police Department investigated the death of a 77-year-old resident at Parkside Manor on March 23. The resident died of asphyxiation by drowning, according to the medical examiner’s report. Her death was ruled an accident, according to the police report.  A complaint investigation released by the Department of Health and Senior Services on May 3 found that Parkside Manor was in violation of state and federal regulations at the time.

“Based on observation and interview, the facility failed to provided an accessible call system to allow residents to call for staff assistance while using the whirlpool bath,” the department’s report read. “Further observation showed the whirlpool area did not have a direct way for residents to request help once in the whirlpool tub.”
A resident had requested to bathe in private, an employee told investigators from the Department of Health and Senior Services. She typically bathed alone but required help getting in and out of the tub. Nursing home employees checked on her every five to 10 minutes because there was no other way for her to request help if she needed it, the same employee told investigators.

On the morning of March 23, a nursing home employee called into the bathroom where the resident was bathing to let her know another resident was being brought in, according to the police report. When she didn’t respond, the employee pulled back the shower curtain to find her floating face down.

The nursing home called 911 just before 9 a.m. and reported that the resident was unconscious and not breathing, according to the police report. Employees attempted CPR, which was unsuccessful.

Parkside Manor had allegedly installed an emergency call system in the bathroom by June 13, according to the plan for correction included in the department’s investigation report. An inspection of the nursing home on Aug. 2 found no violations of state requirements.

This is not the first complaint filed with the Department of Health and Senior Services about Parkside Manor. Since 2014, the department has launched investigations into 14 complaints involving the nursing home.

In January, the department investigated the death of a resident who was prescribed fentanyl patches for pain relief. Caregivers were supposed to remove old patches before applying new patches, according to a department report. A forensic investigator told the department that five patches were found on the resident’s body.

Parkside Manor was also investigated in August 2017 after a resident diagnosed with anxiety, depression and a seizure disorder didn’t receive their medications for 10 days.

In January 2017, the nursing home was investigated after the department found it had failed to conduct the required number of smoke detector sensitivity tests or resident evacuation drills.

The facility was also investigated in June 2016 after failing to properly document, treat and prevent bed sores.


Elizabeth Newman at McKnight’s wrote an interesting review of “The Good Nurse: A True Story of Medicine, Madness, and Murder” by Charles Graeber.  She writes that the most interesting [disturbing] part of the book is not the hundreds of murders by the nurse but the systemic cover up of the deaths.  “But it’s the healthcare system’s desire to make the problem go away without taking responsibility that will strike fear in your heart.”

Nurse Charles Cullen spent 16 years working in different hospitals and a nursing home in the Pennsylvania and New Jersey corridor. He arrived at the nursing home, then called Liberty Nursing and Rehabilitation Center of Allentown, through a staffing agency. His previous hospital, which had fired him for “incompetence, patient complaints and grave medication errors, simply confirmed his former employment.”

“Nobody at Liberty questioned why a nurse with ten years of hospital experience would downshift to a nursing home and a $5-an-hour pay cut,” Graeber writes.  Cullen was the type of nurse everyone loved at first: Willing to take weekend, holiday or night shifts, efficient and, as the years went on, experienced. “His fellow nurses considered him a gift from the scheduling gods, a hire almost too good to be true,” Graber writes.

“Eventually, people started paying attention to the rise of unexplained deaths around them. When Cullen loaded a syringe with insulin and put it directly into a patient’s IV at Liberty, causing his death, he expected questions. But the nursing facility fired a senior nurse, who hit back with a wrongful termination suit. The suit was settled out of court, with the nurse signing a nondisclosure agreement. A few months later, Cullen was fired. But a staffing agency found him more nursing work within days.”

“While that section of the book will make you cringe, wait until you hit the parts where the hospital executives tells the police there aren’t records past 30 days for its Pyxis MedStation 2000 or Cerner, which had its patient charts. The risk manager of the hospital matter-of-factly tells investigators that Pyxis stores records only for 30 days. The investigator, on a whim, calls Cardinal Health, which makes the system. A sales rep is confused when the police officer says he’s looking for older data and asks if there’s “any way to recover anything that far back.” The rep tells him there is no 30-day window, and that Pyxis stores every piece of data.”

“Just pull it up,” he said. “Is there something wrong with your machine?”

There were dozens of people in the book who chose to look the other way. “Or, in the case of certain hospital executives, lie deliberately. It’s hard to know what’s going through their minds: Misguided loyalty to the hospital, fear of scandal, or the sense that it would be more trouble than it was worth to pursue Cullen?”

“Specific laws stemmed from the Cullen case, such as New Jersey’s 2004 Patient Safety Act, which increased hospitals’ responsibility for reporting adverse events, and a later law that said complaints and disciplinary records relating to patient care must be kept for at least seven years.”

“Ultimately, what I came away with is that we need to create healthcare environments where direct care staff who notice suspicious behavior are allowed to speak up. We need better medication tracking systems. We should read books such as “The Good Nurse” to learn how Cullen escaped notice for so many years. And finally, if the police come knocking at your door, it’s in your best interest to cooperate. Not just because you’ll be caught if you lie — and you will get caught — but because at the point where you’re casual about patient lives, it’s time to choose another profession.”

I just finished listening to a 6 episode podcast called Dr. Death.  From Wondery, the network behind the hit podcast Dirty John, DR. DEATH is a story about a charming surgeon, 33 patients and a spineless system. Reported and hosted by Laura Beil.

It tells the story of a Texas neurosurgeon Christopher Duntsch.  He botches so many spinal/neck surgeries that other surgeons lead the charge to the Medical Board to remove his license and even to have him criminally charged.  We’re at our most vulnerable when we go to our doctors. We trust the person at the other end of that scalpel. We trust the hospital. We trust the system.

Christopher Duntsch betrayed that trust.  He claimed he was the best in Dallas. If you had back pain, and had tried everything else, Dr. Duntsch could give you the spine surgery that would take your pain away.  But his patients experienced complications, and the system failed to protect them. Which begs the question: who – or what – is that system meant to protect?

The last episode goes into a lot of the ramifications of his actions, including the fact that none of these patients could find lawyers to represent them because of Texas tort reform which arbitrarily limits compensation for pain and suffering at $250K.  Attorneys wont take the cases because they can’t afford to.  The reporter goes on to explain what Texas thought they would get in return for the reform, but then showed how that didn’t happen.  It’s a good piece of journalism, and might be something good to recommend to those who think tort reform is any kind of answer.

In an article from Fox59.com, the story of Anna Taylor is detailed. Taylor, an 88-year-old woman, was staying at Northwest Healthcare Center in Indianapolis, Indiana for a short rehab period, when a female employee abused her by throwing her in a bed.

“When she came over, she grabbed me by this arm and by my feet like you put a baby in the bed…threw me in there. Threw me in the bed… I said you hurt my arm so bad I don’t know what you did. She never said a word she just covered me up and started to go out.”

According to Mrs. Taylor this worker was on a rampage that night, verbally and physically abusing patients. An X-ray showed that Mrs. Taylor’s arm was damaged in this tirade.

The facility told the family that the woman was fired and that the state board of health was notified. Taylors daughter Laura Thomas was outraged at the event saying, “She was here to get better. This was supposed to be rehab and she’s worse now than what she was when they brought her here because she could use her arms when she came.” The family and Mrs. Thomas want to make sure that this never happens to another family.

This is yet another sexual assault case, detailed at CrimeOnline.com, the story of one resident who has been repeatedly assaulted and where the facility has ultimately failed the resident and her family.

During Delores Green’s residency at the Christian Care Home in Ferguson Missouri, she was raped and sodomized by another resident. The 84-year-old woman’s daughter, Collette, made complaints to the nursing home staff about her mother’s mistreatment, but was ignored. The daughter noticed bruising around Mrs. Green’s private areas, while helping to bathe her. She took her mother to the doctor where it was confirmed that she had been sexually assaulted multiple times. Mrs. Green suffers from physical limitations that prevent her from fighting back, she also has Alzheimer’s which made it difficult for her to tell anyone what happened. Collette commented on the staff at the facility, “They failed her, they failed my mother, they failed her totally.” A suit is pending, and the family has hired many attorneys to stand by their side.

“Raped, sodomized. And no telling when it started or how long it’s been going on. But we know one thing, it has to stop,” the family’s lawyer, Willie Gary, said. Another attorney, Richard Banks said, “Unfortunately the system has failed and it’s not just in Miss Green’s case. The system’s failed a number of times across the country, and these are the people, the voiceless.”

Today’s post is a summary from an article from DailyMail.com, the harrowing tale of an Australian family’s pleas for help to handle their mother’s sexual assault in a nursing home.

On June 29, an elderly woman was sexually assaulted at Bupa Aged Care in Woodend, Victoria, Australia. Sean James Mulcahy, a 62-year-old male resident at the same facility, was charged and put on probation. The son of the victim said that he was not contacted about the situation until September and the facility hasn’t issued any apologies. The woman’s family is outraged at the treatment of this case by both the judicial system and the nursing home. Mulcahy was issued a protection order to stay at least 10 meters away from his victim, but his family say, “We want him removed from the nursing home.”

Behavioral expert Dr. Melanie Lamden has analyzed the behavior of Mulcahy and told the police that he displays narcissistic traits of being manipulative and self-serving. She doesn’t believe he should be living in any facility that houses highly vulnerable adults. A Bupa agent spoke about the situation and said that Mulcahy was being supervised by staff at all times. They also have an agency working on finding him another care facility.

However, this incident has sparked conversation in the community about nursing homes and care facilities. Lisa Flynn, Shine Lawyers national abuse law manager, said people are already worried about placing family members in nursing homes for fear of mistreatment. Allegations like this have forced the government to start investigating mistreatment at elder care facilities.

From an article from KHSB.com:

In March, a 77-year-old woman drowned in a communal bathroom. The woman died at Parkside Manor in Columbia, Missouri. Though it was ruled an accident, a state investigation has found that the bathroom did not have a legally required call system. The Missouri Department of Health and Senior Services investigated and found that at the time of the incident Parkside was violating state and federal regulations. The facility lacked an accessible call system for residents to call for assistance while using the bath. Since the incident occurred they have installed an emergency call system, and now meet state requirements.

The family of an 84-year-old woman filed a lawsuit alleging the woman was raped repeatedly while in the care of  Christian Women’s Benevolent Association, owners of the Christian Care Home nursing home.  A company that provides management services at the nursing home, Riley-Spence Properties, and the owner of the property, CWBA Cedar Lake, also were named in the suit.  Vivian Colette Green filed the suit on behalf of her mother.  The lawsuit alleges the nursing home was negligent in the woman’s care by failing to train staff and properly supervise the residents.

The lawsuit against Christian Care Home in Ferguson accused the facility of allowing multiple sexual assaults to happen while Green was living there and doing nothing about it when the woman’s daughter brought up her concerns.  Green’s daughter told 5 On Your Side earlier this month that she visits her mom every day at Christian Care Home, but during a visit in August she noted some unusual bruising and swelling while giving her mother a bath. She said she asked the nursing home director about her mother’s injuries and was told they were “investigating”. Green  became frustrated by a lack of response.  The next day, she said the injuries were worse.

Green’s daughter immediately removed her from the nursing home and took her to a hospital where doctors performed a rape kit and, according to paperwork from the family, doctors determined the elderly woman was sexually assaulted.  According to the civil suit, medical staff who performed the kit told the family that it appeared the 84-year-old had been raped repeatedly for weeks.  She then called Ferguson police to the nursing home about 10 p.m. Sept. 1 and the department launched an investigation, said Ferguson police Assistant Chief Frank McCall.

“This problem is really really big and it’s rampant and it has hit our family and it can hit your family,” Charmel Johnson, a daughter of the victim, said.

Medicare currently rates Christian Care Home as below average with a history of poor quality of care. Its staffing levels are considered much below the national average. The nursing home was previously flagged for failure to report and investigate abuse of residents and failure to only hire people with no legal history of abuse. The home was fined $78,000 by Medicare after state investigators found a nurse had slapped a resident who had dementia.  Medicare records show other abuse allegations over the past three years and Medicare has fined the facility nearly $90,000 over that time for various violations.

The woman’s son, Kyle Green, spoke to the Post-Dispatch about the abuse this month.

“She could not talk, she could not walk, she could not holler or scream at whoever did this,” Kyle Green said.  “No one should have to suffer like this,” he said.  “It is disgusting to think that someone could do this to anyone, and especially a helpless 84-year-old,” said Kyle Green, Delores’ son.  “She is as innocent as a newborn baby and equally helpless,” her son said.




Two Ohio nursing home employees, Rachel Friesel and Destini Fenbert, have pleaded guilty in the preventable death of a 76-year-old woman who was allowed to wander outside when they failed to supervise her, and died of hypothermia.  Apparently, they failed to supervise the vulnerable adult and then tried to cover up their neglect.  That happens often in nursing home cases.

The Courier reports Friesel and Fenbert pleaded guilty to felony forgery and misdemeanor gross patient neglect. The county prosecutor only recommended that the women receive probation.  Evidence proved that Friesel and Fenbert falsified a log showing someone had checked on Phyllis Campbell, who had dementia, at 2 a.m. and 4 a.m. on Jan. 7. Investigators learned that Campbell left the building around 12:30 a.m. Her body was found outside eight hours later. The overnight low was 2 degrees below zero.

NBC News recently discussed the dangers of sepsis, a severe infection that can quickly turn deadly if not cared for properly.  Year after year, nursing homes around the country have failed to prevent bedsores and other infections that can lead to sepsis, an investigation by Kaiser Health News and the Chicago Tribune has found.  Sepsis is a bloodstream infection that can develop in bedridden patients with pneumonia, urinary tract infections and other conditions, such as pressure sores. Mindful of the dangers, patient safety groups consider late-stage pressure sores to be a “never” event because they largely can be prevented by turning immobile people every two hours and by taking other precautions. Federal regulations also require nursing homes to adopt strict infection-control standards to minimize harm.

However, no one tracks sepsis cases to know how many times these infections turn fatal.  A federal report found that care related to sepsis was the most common reason given for transfers of nursing home residents to hospitals and noted that such cases ended in death “much more often” than hospitalizations for other conditions.

A special analysis conducted for KHN by Definitive Healthcare, a private health care data firm, also proves that the toll — human and financial — from such cases is huge.  Examining data related to nursing home residents who were transferred to hospitals and later died, the firm found that 25,000 a year suffered from sepsis, among other conditions. Their treatment costs Medicare more than $2 billion annually, according to Medicare billings from 2012 through 2016 analyzed by Definitive Healthcare.

 “This is an enormous public health problem for the United States,” said Dr. Steven Simpson, a professor of medicine at the University of Kansas and a sepsis expert. “People don’t go to a nursing home so they can get sepsis and die. That is what is happening a lot.”

The costs of all that treatment are enormous costing taxpayers tens of millions of dollars per year.  Most of which is preventable if the nursing homes were given adequate care.  Yet the systemic failures that produce sepsis persist and are widespread in America’s nursing homes, according to data on state inspections kept by the federal Centers for Medicare & Medicaid Services. Most of the blame, regulators, experts, and patient advocates say, lies in poor staffing levels.  In 2001, a federal government study recommended a daily minimum of 4.1 hours of total nursing time per resident, which includes registered nurses, licensed practical nurses and certified nursing assistants, often referred to as aides.

Nursing home caregivers often miss early signs of infection, which can start with fever and elevated heart rate, altered mental status or not eating.  Too few nurses or aides raises the risks of a range of safety problems, from falls to bedsores and infections that may progress to sepsis or an even more serious condition, septic shock, which causes blood pressure to plummet and organs to shut down. Poor infection control ranks among the most common citations in nursing homes. Since 2015, inspectors have cited 72 percent of homes nationally for not having or following an infection-control program.