Lack of staffing led to death and cover up
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.
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.
