GRAND RAPIDS, Mich. (WOOD) — Mistakes at Michigan nursing homes have killed or contributed to the deaths of 112 residents in the last three years, according to a Target 8 analysis of state and federal reports.
Those mistakes include nurses who forgot to turn on oxygen, who gave morphine to the wrong resident, a woman who died from an allergic reaction to the bananas in her dessert, patients dying from untreated bedsores, preventable falls, and a woman allowed to choke to death on meat she shouldn’t have been fed.
Target 8’s findings surprised not only the experts in nursing home care, but also the state. The state agency that polices nursing homes doesn’t keep track of the numbers.
“One is far too many,” Brian Lee, executive director of nursing home watchdog Families for Better Care, told Target 8. “To have 100, it just screams to me there are serious problems in far too many nursing homes.”
Katherine Winters was among the victims.
“My mother was turning blue, her lips were turning blue, her eyes were bulging, she was reaching out for help, she was putting her hands up to her throat,” her daughter, Deborah Gaus, told Target 8. “All she wanted to do was have somebody help her, and nobody would.”
But they should have, according to a state investigation, and the nursing home’s mistakes killed her.
Her 90-year-old mom was on a soft-food-only diet after suffering a stroke, which meant the nursing home was supposed to grind up her meat so she wouldn’t choke, state reports show.
“Ground up meat like in a hamburg[er] consistency,” her daughter said.
But in August 2012, the state report shows, Hoyt Nursing & Rehab Centre in Saginaw served her beef tips and she choked.
The report shows a dining room worker jumped into action, with help from a nurse’s aide — dislodging some of the meat with the Heimlich maneuver.
But then, what happened next stunned everybody in the room.
The report shows that the director of nursing ran in.
“The director of nursing told her to stop everything,” her daughter said.
Katherine Winters was a hospice patient, which meant she was a DNR — a do not resuscitate patient.
Her rescuers, according to the report, backed away.
A witness told state investigators that Winters had a “scared look on her face,” and was holding her chest as two nurses led her from the dining room.
“They just did nothing, nothing, they didn’t call for help,” her daughter said.
Instead, according to the report, they led her to her room, where she died.
Back in the dining room, the report shows, “you could hear a pin drop.”
“That wasn’t a beautiful death, gasping for breath, you know turning blue, trying to get a breath. My mother was terrified. She had to be. She had to know it was happening” — Deborah Gaus, whose mother died in nursing home
“I was just shocked, I was just shocked,” her daughter said. “The day before, she had just been laughing.”
Her mom was a widowed farmer’s wife whose grandchildren and great-grandchildren called her “Mimi.”
“She was a great grandma and those kids loved her, oh my god, they loved her so much,” her daughter said. “I feel like something was really taken from them because they were just so in love with their great-grandma.”
Despite the state’s findings, Winters’ death certificate mentions nothing about choking. It lists her cause of death as “end stage debility” and “advanced Parkinson’s disease.”
The nursing home, her daughter said, told her family that she had died quietly, of a heart attack. They said Winters “died a beautiful death; the angels came to get her; it was very peaceful.”
“That wasn’t a beautiful death, gasping for breath, you know turning blue, trying to get a breath. My mother was terrified. She had to be. She had to know it was happening,” Gaus said.
NOT A HAMMER BIG ENOUGH
Even the woman in charge of investigating nursing homes for the state was visibly shaken by the details.
“There’s not a hammer big enough for that,” Michigan Long-Term Care Division Director Gail Maurer told Target 8. “I mean, I don’t know how you leave somebody in that situation. I don’t know. It’s horrid. Where was their lack in education that this person suffered so?”
The owner of the Saginaw home, Jon Reardon, told Target 8 that the state report gave just “one side” of the story, but said he couldn’t provide details because of the pending lawsuit. Despite the death, his home has earned above-average grades in health inspections and much above average in overall performance from Medicare.gov.
“There’s not a hammer big enough for that.”I mean, I don’t know how you leave somebody in that situation. I don’t know. It’s horrid.” — Michigan Long-Term Care Division Director Gail Maurer
It was another case — the August 2013 death of 77-year-old Barnell Gunter at Spectrum Health Rehab & Nursing Center in Grand Rapids — that prompted Target 8 to investigate just how often these deadly mistakes happen.
Gunter died after a nurse forgot to check on her clogged tracheotomy tube for two hours, according to a state investigation. It led to a state fine of more than $24,000 and a $150,000 out-of-court settlement.
Target 8 used a link provided by ProPublica, an independent, non-profit newsroom, to sort through thousands of pages of state nursing home inspection reports on Medicare.gov. The reports are kept online for three years.
The analysis revealed 112 deaths linked to mistakes at 81 nursing homes across Michigan since early 2011. That’s nearly one of every five nursing homes. That includes 30 deaths at homes in West Michigan.
“We would not stand for these types of problems in daycare facilities happening to our kids” — Brian Lee, Families for Better Care
Florida-based Families for Better Care, which grades state nursing home care based in part on inspection reports, ranks Michigan as fourth worst in the country. It blames what it calls mediocre staffing levels leading to neglect.
An analysis of Medicare.org shows Michigan is tied with Arkansas for 10th worst in the nation when it comes to serious deficiencies in nursing homes over the last three years.
“We would not stand for these types of problems in daycare facilities happening to our kids, but for some reason in nursing homes, because they’re elderly folks, we tend to ignore the fact they’re being abused and neglected in four of 10 Michigan nursing homes,” Lee said.
30 MEDICAL MISTAKES
State reports list the victims by numbers, not names — Resident no. 101, Resident no. 501. But death certificates, lawsuits, obituaries and autopsy reports helped Target 8 identify some of those victims.
There’s 91-year-old Aileen Rockey, a retired secretary who died of an overdose after nurses at Medilodge of Howell mistakenly gave her morphine meant for another patient for four straight days.
Records revealed 30 deaths tied to medical mistakes — a second morphine overdose, the nurse who forgot to turn on a patient’s oxygen, the patient mistakenly given blood thinner meant for another, patients dying from untreated bed sores.
At least five of the choking cases were because residents with a history of choking were left alone when they shouldn’t have been, Target 8’s analysis found.
More than two dozen deaths involved preventable falls and accidents. They include falls out of shower chairs, off toilets, off lifts, from wheelchairs. At least 15 of those falls were because of poor supervision — either no nurse aides were around, or there was only one when there should have been two.
Dollie McGrew, 85, was thrown from a wheelchair in the back of a Heartland Health Care Center of Kalamazoo van because the driver didn’t buckle her in.
“That wasn’t a way for her to go, no,” her niece Minnie Bynum told Target 8.
BROKEN EQUIPMENT, MISSING MEDICATION
Target 8 also found deaths connected to poor equipment or missing medication.
Last Mother’s Day, while a woman was visiting her mother, her mother stopped breathing during dinner at the Medilodge nursing home in Southfield. The daughter yelled for help, but the unit’s nurse was nowhere to be found. Ten minutes later, a different nurse ran in, tried to use a suction machine to clear the blockage, but the machine wasn’t working, the state report shows.
The missing nurse later told the state she was the only nurse on the unit that day. She said she told staff on the other unit that she was leaving to eat lunch but that nobody was sent to fill in for her. She ate lunch in her car.
In a case investigated in early 2012, a woman eating in her room at Sanctuary at Fraser Villa nursing home in Fraser started choking on food. The woman’s daughter ran out and, on her own, found the suction machine to clear out her throat. But an important part was missing — the tube, making it worthless, the state report shows.
At Boulevard Manor in Detroit, a woman went into diabetic shock, but when the nurse grabbed an emergency diabetic kit, it didn’t have the required medication. It led to irreversible brain damage, then death, according to an investigation completed in August 2012.
“I get angry about it, I get very angry about it because they took something from us that they had no right,” Deborah Gaus, mother died in nursing home
Back in Saginaw, Deborah Gaus, whose mother was allowed to choke to death on meat she shouldn’t have been served, is suing the nursing home.
“I get angry about it, I get very angry about it because they took something from us that they had no right,” Gaus said.
Full statement from Hoyt Nursing & Rehab Centre owner Jon Reardon:
“I appreciated the opportunity to talk with you the other day and again due to resident privacy requirements in HIPPA regulations and litigation I am unable to speak directly on the resident you inquired about. I would add Hoyt Nursing & Rehab Centre is a second generation, family operated facility. For more than 50 years, we have cared for the seniors of Saginaw County and have worked hard to maintain an excellent reputation in our community. Our staff serves residents with compassion and dignity. We are proud of the fact we have earned a Five Star rating from the Centers for Medicare and Medicaid services. We invite area citizens to tour our building and see for themselves the quality care we provide.”