South Carolina Nursing Home Blog : South Carolina Nursing Home Lawyer & Attorney : Poliakoff & Associates Law Firm : Elderly Care, Senior Care

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.

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NBC Connecticut had a tragic article about the outrageous condition of West Rock Health Care Center in New Haven.  Inspections by state investigators uncovered deplorable living conditions.  The West Rock Health Care Center closed its doors on May 14 after the findings.

Anthony Pinto has owned West Rock Health Care since 1998, but last year he ran out of money and had to file for bankruptcy. Pinto blames the Department of Public Health for closing him down.  Inspections found 37 pages worth of violations. Patients were found in beds that were "unmade and with an accumulation of soiled sheets," according to the Department of Public Health.  Residents’ hair was found to be "quite greasy and unkempt," according to the state report. It found "the facility failed to ensure medications were administered timely for four of four residents reviewed." Linens that were worn thin and brown; boxes of medical records soaked in pooling water; and a nurse who cleaned an open ulcer with the same "fecal smeared washcloth" used to clean the patient.

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There were several articles about the lack of investigation by Texas regulators on nursing home complaints.  The Star-Telegram ran an article.  MySanAntonionews.com ran article.  Also American Statesman had one too.

Interviews with families and advocates and a review of thousands of pages of public records by the San Antonio Express-News show some of the city's most frail and vulnerable residents are suffering at the hands of their caregivers. Yet state officials allow troubled nursing homes to continue operating with little or no penalty.

The lack of oversight comes at a human cost. Elderly residents were left for hours in their own urine and feces. Infestations of cockroaches and rats plagued some facilities. Employees yelled insults at residents and handled them roughly. Nursing home staff stole medication and administered the wrong drugs to residents. State inspectors found dirty feeding tubes and broken medical equipment.

The state received nearly 16,200 reports of poor treatment last year in Texas, but most — about four out of five — were unsubstantiated by investigators, who often arrive at the nursing home weeks after receiving the complaint.   When investigators do cite facilities for serious problems, nursing home operators rarely face sanctions. In some cases, the state repeatedly threatened to suspend or revoke the licenses of facilities with chronic problems, yet Texas rarely took action against those nursing homes. Often, a facility promises to do better, state regulators back off, and problems crop up again in a troubling cycle.

Meanwhile, serious complaints against nursing homes have increased in Texas . Complaints about problems that put residents in “immediate jeopardy,” the most serious type of complaint, rose 26 percent since 2006, to more than 950. Complaints of “actual harm,” the second most urgent type of complaint, rose by 10 percent since 2006, to nearly 6,300.

Faced with alarming delays in investigating nursing home complaints, the state is creating teams to speed up scrutiny. State nursing home investigators blew their deadlines to investigate complaints of "high potential of harm" against residents in 66 percent of investigations in fiscal 2009.   In such complaints, mental, physical or psychosocial harm is possible, though not imminent, and an investigation must be initiated within 14 days. 

In response, the Texas Department of Aging and Disability Services will put together teams to speed the state's response. Next month, the department will begin to hire 35 new investigators.

Complaint investigation teams are being set up statewide. Made up of nurses, nutritionists, social workers and general investigators, the teams will be dedicated solely to conducting investigations of complaints and self-reported incidents.

This month, the department plans a two-week blitz to investigate 1,550 complaints at more than 300 facilities, a department spokeswoman said.

The department regulates 1,196 nursing homes statewide and investigated 16,200 complaints and incidents last year.

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The second part of the Star-Tribune's investigation into fatal falls at nursing homes concentrate on the lack of sanctions.  Seventeen days after Agnes Johnson died, state investigators drove out to the White Community Hospital and Nursing Home to interview the staff.  An aide told them she had turned away momentarily while using a mechanical lift to maneuver Johnson from her bed to a wheelchair, and Johnson slipped from the device's sling to the floor, breaking her shoulder and thigh. The OHFC concluded that she died from neglect. It concluded that the aide violated the home's guidelines requiring two people to perform lifts, according to a report. It also determined the nursing home had not properly trained the aide to use the lift.  Despite the mistakes and Johnson's death, the OHFC did not cite the nursing home for violating state and federal regulations. The state found neglect in 17 cases statewide since 2004 where residents were seriously injured or died after falling out of lifts. It has issued citations for errors in only three cases.

When a Minnesota investigation finds that a nursing home was at fault, regulators require nothing more of the nursing home if it fired the worker involved or developed a corrective plan before investigators arrived. Minnesota rarely issues fines against nursing homes.  That is why some health care advocates question the OHFC's effectiveness in holding nursing homes accountable for abuse and neglect -- including falls.  They question a regulatory approach in which more than 1,000 Minnesota deaths were attributed to falls in nursing homes from 2002 through 2008, but the OHFC fully investigated only about 75 of those.

Federal officials audit the OHFC's process for evaluating reports of all types of incidents -- including falls -- and triaging them for possible investigation.  In the past two years, the OHFC has not met federal standards in how it selects cases to investigate.  Last year, federal auditors said that in a sample of complaints, OHFC triaged only 60 percent correctly.

In one of the sampled cases, the OHFC declined to do an on-site investigation into whether a nursing home was using mechanical lifts correctly and if the facility was following physician orders for medical checkups after injury. The auditors said the case should have been given the highest possible priority because other residents who were being moved with lifts were at risk.

But Minnesota's practice of not routinely issuing citations has a drawback, she acknowledged. To help consumers shop for nursing homes, the federal government developed a five-star quality rating that uses the number of citations issued against each home as part of the rating. That means that some substantiated cases of neglect are not reflected in the ratings for Minnesota homes.

In 2005, two nurses aides at Viewcrest Health Center were using a mechanical lift to move a resident from a wheelchair to bed. Without warning, the sling tore and the elderly woman fell to the floor.  The fall left her in great pain and her overall condition deteriorated. Six days later, she died. OHFC investigators discovered that Viewcrest was using a sling that had been patched to fix a broken strap, despite the manufacturer's recommendation to discard and not repair damaged slings. Despite the harm to the resident, the OHFC did not cite Viewcrest for violating government rules.

Viewcrest was found at fault in 2006, when the OHFC ruled that the nursing home didn't properly care for a resident, a known falls risk, who fell and broke her neck. The OHFC did issue citations in that case. Two years later, in 2008, the OHFC again cited Viewcrest because it didn't develop a care plan to help a resident who had fallen 11 times. But in the same year, the OHFC determined Viewcrest was at fault when a resident rolled off a bed and broke her leg while being cared for by a nurses aide. The state regulators said the facility did a poor job training the aide to care for the resident. No citations were issued. Then, in 2009, there was another fall-related incident at Viewcrest. The staff left a resident, who was at risk for falls, alone in his wheelchair and did not activate an alarm that would have sounded as he fell and cut his head. For a third time in four years, the OHFC declined to issue citations for mistakes the home made that resulted in falls.

Helen Fellerman, 93, had a rare disease that made her particularly prone to bleeding. She was also unsteady, forgetful and had a history of falls. So alarms were attached to her bed and wheelchair at Stillwater Good Samaritan Center so staff members would know when she was on the move. But when Fellerman tumbled from her wheelchair on the night of Aug. 31, 2005, the alarm did not go off, an OHFC report noted. She had been left alone for about 30 minutes. She died three days later. The fall had caused bleeding inside her skull, made worse by her medical condition.

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The State Journal-Register had an interesting article about how Illinois is challenging a decision by a Sangamon County Judge Zappa that puts a $10,000 limit on nursing home fines, but the ruling already has affected dozens of cases statewide.  Zappa issued his ruling in a case involving Peoria’s Rosewood Care Center, which had appealed a $25,000 fine stemming from the death of 95-year-old Katherine Martin in 2006.  Zappa found that the department violated state law and bypassed administrative rules when it began to impose fines of more than $10,000 several years ago. He barred the department from enforcing fines of more than $10,000 in past cases that remained pending and any future cases.

Public Health officials believe state law allowed them to boost fines to $50,000 whenever they determined that bad care directly caused a resident’s death. The department in 2006 also began issuing fines of at least $20,000 when residents sustained serious injuries connected with bad care.  High fines rightly punish and deter bad behavior, and promote better care.

Fines involving 40 Illinois nursing homes have been reduced, with the facilities agreeing to pay $10,000 or less, since the Feb. 13 decision.  I bet the facilities jumped at the chance to pay less than $10,000.   State officials are considering reducing individual fines that exceed $10,000 in more than 80 other cases going back to 2006.

The Department of Public Health hasn’t decided yet how to proceed in a pending case against Woodstock Residence, now known as Crossroads Care Center, in which the Woodstock nursing home was fined $300,000 — a record level — in May 2008. State regulators have investigated five suspicious deaths there, as well as a former employee who allegedly used drug cocktails on residents.

The article cited a few examples of cases in which fines against nursing homes have been reduced to $10,000 by the Illinois Department of Public Health because of Sangamon County Judge Leo Zappa’s order in February. These cases remain pending, and a final amount to be paid hasn’t been negotiated:

* Maryville Manor, Maryville: Original fine was $40,000, stemming from an Aug. 6, 2007, inspection that detailed a range of problems including multiple bedsores and pressure sores on residents, a lack of recreational activities and a situation in which a nurse’s aide resigned after injectable anti-anxiety medicine prescribed for a resident was found in the aide’s possession.

* Evergreen Nursing and Rehab Center, Effingham: Original fine was $25,000, stemming from a March 22, 2006, investigation into the June 22, 2005, death of an 84-year-old resident who suffocated after becoming caught in a bedrail that had a piece missing.

* Dearborn Court, Kankakee: Original fine was $30,000, stemming from a Sept. 4, 2007, investigation into the alleged physical assault of a 64-year-old female resident by two employees of the nursing home on Aug. 15, 2007. The employees allegedly hit the resident with plastic hangers, tied her up with a belt, punched her in the head and stomach and tried to choke her.

* Peachtree Estates, Jonesboro: Original fine was $20,000, stemming from a July 15, 2008, inspection that said the facility failed to obtain prompt medical attention for a 73-year-old female resident who fell and sustained a head injury June 19, 2008. About a month before that injury, the resident had fallen and broken her left arm; she also fell on June 20, 2008.

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Our firm has a case against Life Care Centers of America for a facility that they operate in Hilton Head, S.C.  I was doing some research about Life Care Centers and ran across this article in the Chattanoogan.com about Tennesse suspending admissions in one of their facilities.

The article states that Tennessee Department of Health Commissioner Susan R. Cooper, MSN, RN, has suspended new admissions of residents to Life Care Center of Red Bank nursing home effective June 17, 2009, and imposed a one-time state civil monetary penalty of $5,000. A federal civil penalty has been imposed at $6,150 a day until the violations are corrected. A special monitor has been appointed to review the facility's operations.

Life Care Center of Red Bank was ordered not to admit any new residents based on conditions found during a complaint investigation and annual survey conducted May 26 through June 9.  During the survey, surveyors found violations of the following standards: administration, performance improvement, physician services, nursing services, medical records, and pharmaceutical services.

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Tony Bartelme of The Post and Courier had a great article about Alzheimer's, violence, and a cover up in nursing homes using the story of Dwayne Walls. It is a tragic story and clearly preventable.  Below is a short summary of the article.  Dwayne Walls was a resident of Veterans' Victory House, a large nursing home near Walterboro, who suffered Alzheimer's.  One day, they moved Walls to another room and put a dangerously psychotic patient in his old one. His wife warned nurses that Walls would try to return to his old room. "They said they were going to really watch him. But at midnight, I got a call that he had gone to his room and gotten beaten to a pulp," she said.

One night Walls went into another patient's room and climbed in an empty bed. Moments later, another patient walked in. He was 88 years old and also had dementia.  A nursing aide saw the man hitting Walls with his cane. Walls was on the floor, bleeding and unconscious.  An ambulance took Walls to the emergency room and phoned Walls' wife, Judy Hand. That night and over the next four days, they told her that Walls had merely fallen; they didn't mention the beating. Walls spent the next week in bed, and Hand was at his side when he died.   The nursing home's doctor later would write in Walls' file that his patient had contracted fatal pneumonia after becoming "immobile," but that the beating didn't account for this immobility.

The facility had a history of problems. Veterans' Victory House was completed in 2006 at a cost of $28 million in state and federal money. It has five pavilions, and each is named after a South Carolina veteran. It houses 220 residents, making it one of the larger nursing homes in the state. A sign outside says, "Home of the Greatest Generations."   In December 2006, investigators with the U.S. Department of Justice visited the facility: Staff gave patients wrong foods and medications and too often used physical restraints to control behavior problems. They found that the facility was poorly equipped to handle combative Alzheimer's patients.

"There appears to be no formal behavior program for residents diagnosed with Alzheimer's disease, placing residents at heightened risk for the use of physical or chemical restraints to control behavior, and placing them at heightened risk of physical assault by other residents who may become frustrated at their repetitive speech or wandering," investigators concluded.

The state Department of Mental Health owns the facility but has a contract with a private company called Advantage Veterans Services of Walterboro to run it. The company is affiliated with HMR Advantage Health Systems, which is based in Easley and operates 26 nursing homes in South Carolina and elsewhere in the Southeast.

Nearly 80,000 people in South Carolina have Alzheimer's, enough to fill the University of South Carolina's Williams-Brice Stadium, and that memory loss isn't the disease's only troubling effect: More than two-thirds will exhibit some form of agitation or combative behavior.  Aggressive behavior is a normal part of the brain's breakdown, nursing homes don't hire enough people to meet the needs of these patients. Many blacklist Alzheimer's and dementia patients with histories of aggression, leaving already stressed families and loved ones with few options.

There is no cure for Alzheimer's, but doctors are zeroing in on its causes. One leading theory involves proteins. Healthy people have stringlike proteins in their brain cells that normally curl like unfurled ribbons. These ribbons help nourish the cells. But in Alzheimer's patients, these ribbons get tangled, destroying the cells in the process, along with a person's memories and functions that control behavior.

 As happens with about 70 percent of Alzheimer's patients, Walls grew more agitated as the disease marched through his brain, though he was by no means the only person in the wing suffering these effects.  In 2008, staff at the Veterans' Victory House documented in his medical records how another resident pushed him to the floor one month, and how a month later Walls hit another resident in the head with his fist. In June 2008, a resident hit another, who fell into Walls and knocked him to the floor. In July, a staff member found Walls in another resident's bed, his fists balled.   By August, a month before Walls' death, staff noted that he was "aggressive to others and himself," particularly when he was scared. But then the storm clouds cleared. Staff noted on the day Walls was beaten that he had no behavior problems and was moving around well.

Walls had fallen and needed to go to the hospital for X-rays, a nurse said. She didn't mention the beating, or that a deputy had been called to investigate.  Hand drove to Walterboro the next Monday morning for a visit. "I walked into the room and gasped. He was black and blue all over, swollen and on oxygen. I ran out of the room and got a nurse. They came and I asked what had happened." Dwayne had fallen, they told her. Throughout the day, the home's employees stopped by to visit Walls to see how he was doing.  Later that afternoon, four days after the attack, she approached a staffer. "I said, 'He couldn't have possibly gotten that from a fall.' She looked at me and said, 'No one told you? He was beaten.' "  Colleton County Coroner Richard Harvey told her over the phone that the beating contributed to Walls' death, but she was surprised when the death certificate listed the cause as natural and didn't mention the altercation. In an interview, Harvey said he did an autopsy but the results showed that Walls died of pneumonia, not from any other injuries.

The doctor wrote the summary in November, two months after Walls' death, and after an ombudsman hired by the lieutenant governor's Office on Aging visited the home. The agency had received a complaint about "residents that beat other residents," low staffing levels and "residents sitting in soiled diapers."  After the visit, the ombudsman noted the altercation involving Walls but said the agency doesn't investigate resident-to-resident abuse.

The ombudsman nonetheless concluded, "There is a shortage of staff," after looking at the facility's staffing logs. The reports showed the Alzheimer's unit had just one licensed nurse on duty for 52 patients on morning shifts before and after Walls' attack. On one night shift, the wing had no licensed nurse at all. The ombudsman asked the nursing home to follow state regulations, which requires at least two licensed nurses during the morning shift and one on the night shift.

More recently, an investigator with the state Department of Health and Environmental Control made an unannounced visit to the home and found it hadn't properly reported the incident involving Walls and the 88-year-old man who beat him. State law requires nursing homes to report "serious incidents" involving residents who assault others.

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WCCO out of Minnesota had an article about how most violations in nursing homes are under reported.  This seems like common sense since most employees do not want to risk their jobs admitting mistakes, and there is not enough personnel to enforce the regulations or conduct proper investigations. Many complaints are ignored because the nursing home claims the resident was demented.

The system designed to help Minnesotans choose a nursing home for loved ones is under fire. Serious flaws in the system have been uncovered by a nursing home watchdog group.  You might not know about physical and sexual abuse happening inside the nursing home.

Wes Bledsoe, the founder of a nursing home watchdog group, says he can prove that the rating system on Medicare.gov does not show what is really going on in nursing homes.  For example, after all of the well known abuse at Good Samaritan Society in Albert Lea, a report from the Minnesota Department of Health says no deficiencies were noted at the nursing home.

At a different facility in the state, someone saw an employee pick up a nightgown soaked with urine and that worker "shoved it in the resident's mouth and told her to shut up." Again, the Department of Health didn't note any deficiencies.

A spokesperson from the Minnesota Department of Health said "If a facility has taken appropriate steps to correct problems, they may not be cited with deficiencies."  However, when deficiencies aren't noted, they don't show up on the Medicare site, so there's no way you could know if you've only checked that Web site.

Bledsoe said it's happening all the time. He found that 80 percent of confirmed abuse cases in Minnesota in the last four years didn't get reported to the feds.

"I think it's bureaucratic mumbo-jumbo that's deceiving the consumers and the American public about what's really going on in our long-term care facilities," said Bledsoe.

Bledsoe said another big problem is the star system on the Medicare Web site. On a lot of the nursing home Web sites, a lot of the information is not available, so he's wondering how they can give a place four or five stars when there's no information.

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Stephanie Flemmons at sflemmons@acnpapers.com had a great article in the Plano Courier.  The article discusses how a complaint was handled by the state agency responsible for investigating nursing home resident's complaints.  Richard Ward was a resident who received a serious medication error that could have killed him.  The Texas Department of Aging and Disability Services ruled not to take any action against a facility that almost killed him.

“It strikes me as, you may have made a medication error that could have killed someone, but oh well,” Ward said. “We are not working on cars here, we are working on people.”

Ward’s formal complaint stated that the Life Care Center of Plano failed to administer the proper medication, which almost caused a fatal heart attack.  When Ward admitted himself to Life Care, he provided the nursing staff with an itemized list of the types of medications he was required to take, what the dosages were and the actual medications.

Ward said the nursing staff failed to administer his Coumadin.  He became aware days later when his physician conducted her examination.  “When the doctor conducted her physical it was almost too late,” Ward said. “She panicked after the results from an INR test came back normal. A normal level for a person with my heart conditions is a dangerous place.”

The physician immediately ordered Lovenox injections and Coumadin.  “I felt like I was on the brink of death,” Ward said. “I panicked.”

That night on May 28, Ward received his required Coumadin.  The next day the errors kept occurring. He received his Lovenox the next morning, but did not receive it that night.

“Medication time is at 9 p.m. and I waited until 10:30 p.m. to ask the nurses,” Ward said. “They argued with me. I had to force them to look it up.”   Ward said they realized they made a mistake, but at that point he had had enough.  “I thought these people were going to kill me,” Ward said. “That was their last chance.”

The state agency ruled this claim as unsubstantiated or unverified.

“I am flabbergasted,” Ward said. “I brought them a typed list of every medication that I picked up from the Medical Center of Plano before I admitted myself.”   Ward discharged himself from Life Care.  He reviewed his medical records.  The typed list was no longer in the records.

“They took it out because it showed blatant negligence,” Ward said. “All they had to do was lose one piece of paper and they wouldn’t look so bad.”

Ward’s second complaint alleged that the facility failed to maintain accurate clinical records.  DADS did find that the facility did have his name incorrect, but they did not issue a citation.

“How would they know who they were giving medicine to if they did not have the patient’s correct name?” Ward said. “At some point they gave me medicine, without the correct name on my records.”

Ward wrote prescriptions for 20 years in the Army and as a civilian.  He is concerned that the state agency’s rulings on both claims proves future such rulings could take the life of an innocent person.  “You just can’t make a mistake like this and not have any repercussions,” Ward said. “If they are doing this to someone who is awake and alert and knows how to read medical records, I’m sure they are doing this to someone else. I’m not an isolated case.”

Ward said they never contacted any of his family members or even asked him many questions regarding the claim.   According to DADS annual report, medication errors are No. 8 in their top 10 list for complaints.

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