Failure to Report and Investigate
Lexington Herald-Leader have been running a series of great articles on the failure of authorities to investigate complaints or for the facilities to report complaints and incidents. See also article from WLWT. The article uses the death of Ruby Goode as an example of lack of reporting, investigating, and prosecuting neglect and abuse of vulnerable adults.
The death of Ruby Ethel Goode in a nursing home was one of more than 100 incidents over three years in which Kentucky nursing homes were cited for violating state regulations. Few of those cases were prosecuted as crimes. When Brenda Goode Woitke learned that her 93-year-old mother had died in the Calvert City Convalescent Center, she assumed that she had died of natural causes. But the death of Ruby Ethel Goode was far from natural or peaceful. She was found on the floor with her head stuck between the side rail of the bed and the mattress, her neck unnaturally stretched.
Not only did officials at the Western Kentucky nursing facility fail to tell Woitke how her mother died, but they intentionally hid the facts. A nurse told others "not to talk about this to anyone because they would all get in trouble," according to a state citation issued to the nursing home after Goode died. "There was no evidence the family, the physician, the administrator, or the director of nursing were immediately notified" of how Goode, known as Ethel, died, according to a Type A citation, which is issued by state regulators when there is an immediate threat of death or injury to a nursing home resident.
Goode's own doctor said that if he had been told about the circumstances of his patient's death he would have contacted the coroner himself. After a local newspaper reported how her mother had died, she walked into the office of Paducah lawyer Richard Walter and said: "I just want to know what really happened."
The civil lawsuit that was filed as a result has been settled for an undisclosed amount. Through the civil process, Woitke learned that the facility had not thoroughly assessed whether her mother — who had memory problems, was at a high risk of falls and frequently slid to the bottom of her bed — should be left alone with her bed rails up.
"It's not about the money," Woitke said. "The truth of the way my mother died was withheld from me deliberately. I don't want this to happen to another family."
But when prosecutors reviewed Goode's case, they said there was not enough evidence to charge anyone with a crime — even though regulators said the nursing home failed to adequately assess whether Goode should be placed in a bed with side rails. The citation even said that might have prevented her death.
A Herald-Leader examination of 107 Type A citations issued over a three-year period by the Kentucky Cabinet for Health and Family Services Office of Inspector General found a number of gaps in the system that mean few nursing home deaths are ever prosecuted as neglect or abuse. They include:
■ Police and coroners are rarely notified of nursing home deaths or serious injuries.
■ Although the state sends all of the most serious nursing home regulatory violations to the attorney general's office, that office can only prosecute with the permission of local prosecutors. And local prosecutors say they seldom hear about the cases.
■ The attorney general's office misplaced or never received at least five citations issued by the cabinet from December 2006 through 2009.
The responsibility for criminal prosecutions involving long-term care facilities is spread over several agencies, with no single authority as overseer. That results in confusion and finger pointing among officials who do not want their offices blamed for not protecting the elderly.
The inspector general says it's the attorney general's responsibility to review nursing home citations and determine whether a crime was committed. The attorney general says that the inspector general or Adult Protective Services office can notify local police or prosecutors when criminal activity is suspected.
The 107 citations involved 18 deaths and 30 hospitalizations. Seven of the type A citations resulted in criminal charges. Eight cases are still open.
Cases where no charges were filed included those at facilities where a man wandered away and froze to death; a patient who was not monitored lost 87 pounds in 19 days and was later hospitalized; and a patient who fell and broke her hip but did not receive medical attention for seven hours.
The examination also found that nursing home employees who are prosecuted seldom serve jail time.
Much of the problem, experts said, can be attributed to the lack of a central authority to oversee investigations and prosecutions of incidents at nursing homes. Advocates for the elderly, family members and attorneys say that nursing home deaths and injuries are not often scrutinized as potential crimes because the victims are elderly and often have serious illnesses.
If many of the same things happened to children, there would be a public outrage, said Kathleen Quinn, the director of the National Adult Protective Services Association, a trade group for adult protection workers.
Most nursing home incidents "are not investigated at all," said Dr. Barbara Weakley-Jones, Jefferson County coroner and a former state medical examiner who first noted Kentucky's lack of attention to nursing home deaths in a 1991 study. "Unfortunately some nursing homes try to cover up what happened," she said.
Experts say criminal prosecutions in nursing home cases are difficult. Even if it seems clear that a crime was committed, it may not be certain which staff member or members did it. And elderly residents often cannot tell what happened.
Consider the case of Aden Owens, a construction worker who suffered a closed head injury at age 61 when a concrete slab collapsed. He entered Sunrise Manor Healthcare and Rehabilitation in Somerset in 1999. But his family became concerned about bruises he received — 114 injuries of unknown origin over seven years, the family alleged in a civil lawsuit.
Stephen O'Brien III, a Lexington attorney who represents Owens' son Bryan, said Owens' worker's compensation carrier required him to be at Sunrise Manor. The family spent several hours a day at the nursing home and in 2006 placed a hidden camera in his room.The videotape showed a nursing assistant pulling Owens' hair, twisting his fingers and striking his hands. Another nurse's aide is seen striking him, jerking him by his neck and placing a knee on his chest while changing his diaper. After Owens fell out of bed, an aide left him on the floor while changing his bed, the videotape shows.
Bryan Owens said he couldn't understand why his father's case wasn't prosecuted, while in another case, three nurse's aides caught on a hidden camera abusing an elderly woman at Madison Manor nursing home near Richmond in 2008 were prosecuted and convicted.
In the Madison Manor case, one aide was found guilty of abuse after she roughly handled 84-year-old Armeda Thomas. Another was convicted after she ate Thomas' food and said in records that Thomas ate it.
One key difference between the cases — Thomas' case received widespread media coverage. Owens' didn't.
