M.E.: Nursing home should have reported death details

GRAND RAPIDS, Mich. (WOOD) — Her family thought she had died peacefully in the middle of the night at a Spectrum Health nursing home on Fuller Avenue NE in Grand Rapids.

But Target 8 found state records showing the nursing home didn’t tell Barnell Gunter’s family, or the medical examiner, everything.

Among the details left out: a clogged breathing tube and the nurse who forgot to check it for two-and-a-half hours.

The mistake led to a fine of more than $24,000 and led Spectrum Health Rehab & Nursing Center to pay the family $150,000 in a settlement, state and court records show.

“They covered it up,” said a woman close to Gunter. “They covered the whole story up. They don’t want the truth to come out because the truth comes out, they know they’re going to get in trouble.”

Gunter, 77, a mother of six and a grandmother, had been sick for years, according to Kent County Probate Court files.

She had suffered a stroke, was diabetic, had dementia, schizophrenia and needed a tracheostomy tube since her heart attack in October 2012.

“It was the only way she could breathe,” said the woman, who didn’t want to be identified.

Gunter’s children have signed a non-disclosure agreement with Spectrum, so they refused to comment.

Doctor’s orders show Gunter wanted the nursing home to do everything it could to keep her alive — including suctioning the trach tube so it wouldn’t fill with mucus, records show.

“It was kind of sad to see her diminish in her health,” said the woman close to Gunter. “The sicker she got, she wasn’t as spunky as she was, and it took away her happiness when she got sick.”

She was on the second floor of Spectrum Health Rehab and Nursing Center, the old Kent Community Hospital.

With 278 beds, it’s by far the biggest nursing home in Kent County. But it’s also one of three in the county — out of 25 — to get the lowest rating in state health inspections: much below average.

The woman said that despite her illnesses, her family wasn’t expecting her to go when she did.

“She was talking just fine the day before it happened, so I know she was in good spirits,” the woman said.

Which is why, she said, the family asked the state to investigate after learning she died early in the morning on Aug. 30.

A complaint was filed 20 days later with the Michigan Bureau of Health Care Services Long-term Care Division, which monitors nursing homes — but state officials told Target 8 it was not self-reported by Spectrum.

A Spectrum Health spokeswoman acknowledged the home did not report the incident to the state, but it said it cooperated with investigators.

The state investigation revealed new details of Gunter’s last hours.

State records show a certified nurse assistant was filling in on the short-staffed second floor on Aug. 29.

When she checked just after 11 p.m., Barnell appeared restless, moving her head back and forth. Her trach tube “sounded full,” according to the state report.

The assistant told the registered nurse, who said she would suction it.

But the RN was busy with a patient who had fallen and later told the state “it just slipped my mind.”

Two-and-a half hours later, at 1:40 a.m., she checked on Gunter.

Gunter wasn’t breathing. She had no heartbeat.

It’s possible, said Kent County Medical Examiner Dr. Stephen Cohle, that she suffered that night in her room.

“If they are alert and suddenly are unable to breathe, then I think it could be uncomfortable,” Cohle said.

A nursing home respiratory therapist rushed to Barnell’s room on a “code blue,” records show. She told state investigators that the nurse was holding the tube and “kept saying she couldn’t get it back in.”

The therapist put it back in. But, by then, the patient was cold and blue and her arms were hard to straighten out, like she’d been there for a while, records show.

The ambulance paramedic who treated her told the state: “No one seemed to know when or how the trach came out, or for how long it had been out.”

Gunter died despite rescue attempts at the home and at Butterworth Hospital.

The death certificate lists the cause of death as natural, making no mention of the trach tube.

A separate medical examiner’s report, obtained by Target 8, shows it appeared Gunter’s trach tube dislodged during respiratory failure and cardiac arrest, but the report mentions nothing about the clog or

the two-and-a-half hour delay.

“We should be told, our investigator, from the get-go, what happened, everything that happened,” Cohle said.

Cohle said she could have survived, had the nursing home immediately cleared the clogged tube.

“She may not have died right when she did,” Cohle said. “She may have lived minutes longer, a day longer, maybe several weeks. I assume she’s in pretty bad shape if she’s in that situation, but she probably wouldn’t have died when she did.”

After the state investigation, the federal Centers for Medicare and Medicaid Services (CMS) fined the

home $24,100 for putting residents in “immediate jeopardy.”

It also withheld Medicare and Medicaid payments for new patients for nearly seven weeks.

Probate court records show the nursing home settled with the family for $150,000 — a settlement approved by a judge late last month.

“The issue is what seems to be neglect on the part of the nursing home,” Cohle said. “They didn’t report it to us. As the ME, that’s my biggest concern… I want to know stuff, and I don’t care who it is, what institution it is. I’m wearing my medical examiner hat, I work for the county and this goes into a report that’s public record.”

Cohle said his office, which investigated the death, likely would not have changed the cause of death — from natural — but may have included the blocked airway.

It also would have immediately reported the incident to the state, he said.

“There may be mistakes, but if there are, report them, get them out in the open, or at least get them to the state agency, ‘Hey we screwed up,’ and tell the ME.”

After the investigation, Spectrum took the registered nurse “off the schedule,” state records show. It also agreed to make changes, including checking on trach patients every hour.

Target 8 tried to reach the president of Spectrum Health Continuing Care, Jeffrey Mislevy, but he wasn’t home.

A Spectrum spokeswoman later released a statement: “I can now confirm that we did not formally self-report. We did fully cooperate with the state and disclosed information. We also reached a settlement with the family and implemented a preventive action plan that was reviewed and accepted by the state.”

Spectrum also said it regretted the unfortunate death and that it had expressed its sympathy to the family.

The woman close to Gunter said Spectrum should have taken action against the home’s administrators.

“They should be fired, immediately, and they should be prosecuted,” she said. “That’s how I feel, because if it was their loved ones, they’d feel the same way.”


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