Dallas News had another article about the lack of supervision, enforcement, and investigation of nursing home complaints of neglect and abuse in Texas. Regulators have repeatedly found problems and cited violations at Veterans Land Board, which the General Land Office is the parent agency of the veterans board. But the criminal investigation into Bryson Vanderbilt, 25, and Connie Mae Johnson, 52, charged with "striking, pushing, grabbing and forcefully handling" two residents in separate incidents languished for over two years because of confusion over who should investigate, cumbersome bureaucracy and conflicts among local police, state officials and home administrators,
The witnessed allegation of abuse includes a CNA grabbing a 97-year-old from his wheelchair and slam him into his bed. Another employee at the home was accused of punching and trying to choke Albert Teague, 84, a Marine who fought at Iwo Jima. Felony charges were finally filed against the ex-employees last month. The allegations that resulted in the recent criminal charges were first checked by Big Spring police in late 2007. But interviews and records obtained by The News through state open-records laws indicate that a criminal investigation was delayed partly because the police yielded to the state agency that inspects nursing homes.
Senior Dimensions, the Austin-based firm that manages the home under a state contract, said it contacted the police and began an internal investigation. The police report, dated Nov. 9, 2007, said Cpl. Adam Stovall spoke with a unit manager who said a certified nurse aide had seen a male co-worker abusing one of the residents.
But, Stovall wrote, the home's administrator, Bob Kerr, would not give police copies of the employee statements about the incidents.
Stovall said he saw one statement, from resident Wilson Sikes, who said he had slammed Vanderbilt's hand in his nightstand because the man was going through his belongings. Vanderbilt then "lifted his wheelchair and dumped Sikes in his bed, then sat on him and slapped him across the face with gloves," the police report said.
Sikes recounted the same abuse to Stovall, who said he saw no "obvious injuries" to Sikes.
Kerr, a Senior Dimensions employee, told The News that he couldn't recall whether he declined to turn over witness statements. But if so, he said, it was "because we were in the process of doing an internal investigation and we felt those were part of our internal investigation."
Senior Dimensions said last week that it wouldn't release a copy of its internal investigation.
Over the past three years, inspectors from the state's Department of Aging and Disability Services have documented several problems at Amarillo veterans home.
The Veterans Land Board, the division of the land office that runs the homes, says the price is cheaper than most privately owned nursing homes because of extra funding from the Department of Veterans Affairs.
Inspections by the state's Department of Aging and Disability Services, reviewed by The News, show a series of problems at the Amarillo home, which is run by San Antonio-based Touchstone Communities. Among them:
• A woman was hospitalized with gastrointestinal bleeding after a lab test, including blood work, was not done and a staff member misread her doctor's orders. As a result, she received too much of a blood-thinning drug, resulting in an "abnormal bruise" from her lower back to her right leg from a fall.
• An elderly woman with Alzheimer's was found on the floor with the neck of her nightgown caught in her bed's rails. The inspection found that she had redness around her neck. A previous assessment of the woman said a staff member needed to get her in and out of bed, but it didn't call for the use of safety devices or restraints, which are used to prevent falls.
• From September 2008 to April 2009, four residents suffered first- and second-degree burns from spilled hot coffee. After three residents were hurt, an employee put a sign on the coffee machine for her colleagues: "You will bring coffee down to 140 degrees by adding ice. No exceptions. You will go to the Administrator's office to explain why you burnt someone!!!"
\The Big Spring home, which opened in 2001, is a sprawling complex that state regulators cited the home for several violations, including:
• A resident, unattended in his wheelchair, left the veterans home building. The resident was found in the cold darkness, lying on the cement about 80 feet from the front door, with swelling to his left eye and cheekbone. He spent two days in the hospital.
• A man choking to death on a radish, although his physician earlier had ordered a soft diet for him. The man had Alzheimer's disease, schizophrenia and dementia.
• A resident with Parkinson's disease who was not offered timely counseling or psychiatric help last year after he talked three times about death and suicide, and then wrapped his feeding tube around his neck twice in one day.
• Lack of a system for ensuring that beds were in locked positions after a man fell when his bed rolled. The home also did not properly supervise another resident who had been found on the floor at least four times in less than two months.
In one case, a man who was known to be at risk of falling tumbled out of bed and then fell twice in the bathroom, hurting himself each time. An inspector asked an employee why she didn't investigate the last incident.
"I guess I missed that one," the employee replied, according to the inspection report.
