KALAMAZOO, Mich. (WOOD) — Dollie McGrew, an 85-year-old widowed nurse technician living at Heartland Health Care Center of Kalamazoo, was known as Grammy.
She was headed to an oral surgeon at the University of Michigan in Ann Arbor, 100 miles away. A nursing home maintenance man strapped the electric wheelchair to the bus floor, but didn’t buckle McGrew into the chair.
Those straps built into the bus’s wall? He said he didn’t know how to use them. He had never driven a patient before.
Nobody had trained him.
Not far from their destination, he slammed the bus into a curb and blew a tire. The impact threw McGrew to the floor, and killed her. Her cause of death is listed as sudden cardiac arrest caused by a fall from a wheelchair during a minor motor vehicle collision.
“That wasn’t a way for her to go, no,” her niece, Minnie Bynum, told Target 8.
After an investigation into the July 2011 death, the Michigan Bureau of Health Care Services Long Term Care Division, which inspects nursing homes for the federal government, found Heartland’s practices put residents in immediate jeopardy.
The fine: $12,100.
FINES LOWER THAN NATIONAL AVERAGE
A Target 8 investigation uncovered nursing home mistakes in Michigan that led to 112 deaths over the last three years. They include medical errors, failing to perform CPR on dying patients, preventable falls, poorly treated bedsores.
The state has fined Michigan nursing homes a total of more than $1 million over the last three years in cases involving deaths, according to a Target 8 analysis. But Target 8 found huge disparities in fines: the highest was $141,000, but some were just a few thousand dollars.
The average fine in Michigan death cases in which the amounts were available was a little more than $21,000, the analysis showed.
“You make a mistake, you’re supposed to pay for it” — Minnie Bynum, niece of patient killed in crash
Michigan ranks second in the nation when it comes to how many nursing homes it penalizes — not just in death cases — but its fines are thousands of dollars below the national average, according to an analysis by ProPublica, an independent, non-profit newsroom.
“If you’re going to hit nursing homes for neglect, you’ve got to hit them where it hurts, and that’s in the pocketbook,” said Brian Lee, executive director of Families for Better Care, a Florida-based nursing home watchdog group. “Sixteen-thousand-dollar fines, $20,000 fines, even $65,000 fines are nickel and diming nursing homes. It’s not going to change their behavior.”
“You make a mistake, you’re supposed to pay for it,” McGrew’s niece said. “I don’t think my auntie should have passed and nobody do nothing about it. There should be something done.”
Something more than a $12,000 fine.
McGrew’s children thought so too, filing a lawsuit against the home. The home settled for $900,000.
Heartland nursing home Administrator Bette Morris refused to talk about the death. In a written statement, however, the home’s spokeswoman later called it an isolated incident that has been addressed.
The association that represents most Michigan nursing homes says it works closely with them to improve safety.
“This is a big system,” said David LaLumia, president and CEO of the Health Care Association of Michigan. “In Michigan, there are around 13 million days of care delivered each year in skilled nursing facilities and for the three-year period you looked at, you can multiply that times three. It’s human beings caring for human beings and errors occur and, once the incident has occurred, as tragic as it is, the important thing is to find out what happened and to fix it in such a way that it never happens again.”
Medicare.gov rates Heartland in Kalamazoo as below average in health inspections, but above average in its overall performance. The state has fined it $36,498 over the last three years.
A BIGGER HAMMER
On the other side of the state, a fatal mistake made by Medilodge of Howell — mistakenly giving morphine to 91-year-old dementia patient Aileen Rockey for four straight days — cost that home $16,000.
The pain killer was supposed to go to another patient.
“Sixteen-thousand dollars in that incident is really the cost of doing business for the nursing home,” Lee said.
States investigate nursing homes for the federal Centers for Medicare and Medicaid Services and recommends fines, which must be approved by the feds, said Gail Maurer, director of Michigan’s Long Term Care Division.
In cases involving a death that pose “immediate jeopardy” to other patients, the flat fine is set at $10,000 by the state.
“Sometimes, they’ll bump it up, sometimes they knock it down. And I don’t know what their formula is,” Maurer said.
That’s what happened, the state said, in the death of Alfred Vincent, 77, who died at MagnumCare of Hastings in January 2013. State spokesman Jason Moon said the state recommended a $10,000 fine, but the Centers for Medicare and Medicaid Services reduced it to $5,818.
The state also requires homes to take steps to make sure mistakes don’t happen again.
But even the state says it wants bigger fines in cases like the morphine overdose, or the death of Dollie McGrew in the back of the bus.
“I think you have to talk to the federal government,” Maurer said. “I can wish everything I want.”
When asked if she’d like a “bigger hammer,” Maurer said: “Me, as the state, I probably would.”
Statement from Kelly Kessler, spokeswoman for Heartland in Kalamazoo:
“We were deeply saddened by the death of one of our patients. This was an unfortunate, isolated incident in 2011. We have reviewed our systems and training to avert such an issue in the future. The well-being of our residents is our primary concern. We continue to be committed to each resident’s emotional and physical well-being. In accordance with federal and state laws and regulations, we are not permitted to discuss individual patients who reside or have resided in our center due to our commitment to patient confidentiality and resident rights.