A look at 'unexpected' deaths in community care homes

This article was written by Sandy Hodson

The Augusta Chronicle requested the investigative reports of all 2013 deaths of developmentally disabled people living in community-based care homes. The reports were prepared by the state’s Department of Behavioral Health and Developmental Disabilities. The following summaries are for those people whose deaths were categorized as unexpected. The deaths of three patients detailed in the series are not included. If family members objected, those summaries were excluded:

• A male patient transferred from Central State in February 2011. He needed partial to full physical support for most daily activities, and he was on a pureed diet. Two years after he was moved into Grace Personal Care Home/Caring Hand Inc. in Gwinnett County, he was dead. According to the investigative report, on Feb. 2, 2013, the patient took his medicine with a glass of milk about 8 p.m. and went to bed. When the caregiver checked on him about 3:30 a.m., he was having trouble breathing. The caregiver called 911 and started CPR without checking the patient’s pulse first. He died at Grady Hospital the next day. The care home had one incident of unsubstantiated neglect between August 2012 and Feb. 4, 2013. The patient had been hospitalized in September 2012. Two nurses formed Caring Hands in 2010, and they have four homes in Gwinnett County. An investigative report lists both as registered nurses, but the license of one of them expired Jan. 31, 2007.

• The cause of death for a 50-year-old man who died Feb. 4, 2013, in Warner Robins was “unspecified natural causes.” That morning, he took a shower as normal, according to his direct care staff, but lay on a bed for a while before getting dressed. He was unsteady on his feet, and after staff took him grocery shopping, they put him back in bed and called 911. Suddenly, according to the investigative report, blood started pouring out of his nose and mouth. He died soon after. The man could communicate verbally and by writing, lived in his own apartment and took his own medicine. Abilities Discovered, a nonprofit organization that offers assistance to developmentally disabled residents of middle Georgia, provided services such as cooking, cleaning, monitoring of medications and help with finances from 1991. But staff was not trained about his medical condition. A review found staff negligent for not performing CPR.

• The day before a 40-year-old man died, a caregiver at his RHA Healthcare home in Milledgeville told a licensed practical nurse that he had dried blood in his nose and on his face. At the Oconee Regional Medical Center emergency room, a decision was made to hospitalize him as he had low blood pressure and high pulse rate, along with blood in his rectum. The patient became upset about 11 p.m. May 9, 2013. By 12:15 a.m., he had stopped breathing and had been bleeding from the nose and mouth. The patient had been in community care about six years, but his care was transferred to RHA Healthcare in July 2012. The Baldwin County medical examiner declined to perform an autopsy. The cause of death is listed as gastrointestinal bleeding.

• On May 15, 2013, a 52-year-old male patient was found not breathing during a 5 a.m. bed check at the Thomasville care home where he lived after being transferred from a hospital in April 2011. He had limited verbal skills and needed one-on-one assistance throughout the day for daily activities. He became weaker and less able to walk without help while living in the home. He would drop to the floor and “scoot.” On May 12, 2013, he fell and hit his head. The Thomas County coroner declined to request an autopsy.

• One month after a 51-year-old patient reportedly had an annual physical with normal results in June 2013, he was dying. The patient suffered repeated bowel accidents. The next day, he didn’t want to get up and was unsteady on his feet. He took one bite of breakfast and spit it out and went back to bed. His breathing was “wrong,” and he had another accident in bed. Staff found him not moving, and when they tried to clean him up, he vomited. Staffers called 911. He died in Bacon County hospital six days later of septic shock, according to a death certificate. He had lived at Cypress Hill Community Home in Alma in Bacon County for six years. A report indicates he was scared of the bathroom and water. The day he became deathly ill, only one staffer was on duty at the home with four patients.

• A patient died July 14, 2013, at a Gwinnett County home where he had lived with a ResCare contract employee for 13 years. That morning, his caregiver found him unresponsive on the floor. He started CPR and called 911. The caregiver reported that the patient had not been sleeping well for six months and he was working with the doctor to find a medication to help. The doctor changed the medication July 11, 2013, but the caregiver couldn’t get the prescription filled because it hadn’t been authorized by Medicaid for payment. According to an investigative report, ResCare said it pays if there’s a delay, but no explanation was provided for why it didn’t in this case. An investigation was critical of the caregiver’s incomplete medical records. It also said ResCare needed a policy or written guidelines on what to do when there are delays in authorization for medicine.

• A 31-year-old woman lived in a ResCare home in Gainesville for four years before she died July 31, 2013. According to the investigative report, she stood up from the dinner table, began screaming and fell to the floor dead. She had fainted twice July 21 and again July 25. Her cause of death was a blood clot. Her caregiver told the investigator that “fainting” was a behavioral issue 10 years earlier.

• According to an investigative report, on Sept. 1, 2013, a 41-year-old woman was sitting on the back patio when she had a large bowel movement, the first in three days. She was given a shower and put to bed. Ten minutes later, she was found unresponsive. The day before, she saw a guardian health care worker and no problems were noted. She needed constant care – 24/7 by awake staff. The house manager in the Stone Mountain care home said she “would hit, spit and grab at staff, usually at bath time,” but would calm down if given time. She was moved into the ResCare contracted home in 1997. An Aug. 22, 2013, inspection of the home noted a meager food supply, expired milk and ham in refrigerator, and the need for repairs.

• In August 2013, the care plan for a 62-year-old man called for enhanced staffing because of complex medical needs. By Sept. 8, 2013, he was dead. The patient needed direct care for moving, dressing, etc. He was non-verbal, communicating by pointing, gesturing and facial expressions. The patient was cared for through Sunrise Community of Georgia in the Cartersville home where he lived with three others. His cause of death was heart failure, according to the death certificate. He had had pneumonia and the flu.

• A 61-year-old woman died Sept. 8, 2013, three days after an Urgent Care visit for shortness of breath. She lived at a privately owned personal care home in Macon where she was found unresponsive about noon Sept. 8. The staff called 911 but did not do CPR, saying they couldn’t move the woman out of her wheelchair. According to the investigative report, they didn’t know the arms of the wheelchair could be folded back to make it easier to remove the patient.

• A 68-year-old man who died Sept. 16, 2013, had lived on his own in Athens for 12 years with support from Georgia Options, a nonprofit organization that provides supported living services in the Athens area. On July 30, 2013, he suffered a severe adverse health event and was hospitalized at Athens Regional Medical Center the next day. When discharged, he needed the help of a second staff person and was placed on a pureed diet. He was home only a short time before he returned to the hospital Aug. 4. Georgia Options staff wanted to care for the patient, but it was not allowed to bill for hospice services.

• A 60-year-old man was removed from Central State and placed in a care home in May 2011. According to the staff at his ResCare contract care home in Stone Mountain, he liked to sit outside on the screened porch “for hours.” The investigative report stated his ResCare contract care home in Stone Mountain was staffed 24/7 but contained no list of the staff. The patient needed help for all daily activities and spent hours sitting on the screened porch. According to the report, he had been hospitalized at Emory University for severe vomiting in January 2013 and returned at the end of the month for the same ailment, and again in April and May 2013. The man died Sept. 19, 2013. A death certificate listed the cause as “respiratory failure – pulmonary embolism and cerebral palsy.”

• A woman who could sometimes say one- or two-word phrases and communicated through “laughing, hitting and screaming,” according to her caregiver, died Sept. 22, 2013, at the rented care home in Columbus where she lived. She needed help with all daily activities. Her meals were pureed, and she needed assistance to eat. She was hospitalized at Columbus Regional Healthcare Medical Center in February 2013 for four days, and she had numerous doctor visits in March, April, May and June. After moving into the home in January 2013, a psychiatrist adjusted her medication eight times. Medication was a factor in her death, according to an investigation. It determined that neglect was substantiated for her caregiver’s failure to continue CPR for three minutes, and when it was begun the patient was on a bed instead of the floor. ResCare’s overseer of patients reported that patient care was good and there were no problems. The overseer’s actual reports were never provided to the investigator, however.

• A 61-year-old woman died of sepsis and pneumonia Sept. 25, 2013, at the privately owned care home in Dallas, Ga., where she had been moved nine months earlier. In January 2012, she was diagnosed with a medical condition her physician described as brain shrinkage. She required help with most daily tasks and one-to-one supervision. She could hold a spoon and feed herself with monitoring and assistance. On Sept. 24, she was at a kitchen table when staff realized she wasn’t breathing.

• A 54-year-old man died Sept. 25, 2013, after choking on a peanut butter sandwich at a Macon day care facility. The patient required one-on-one supervision during mealtimes. His diet required bite-size pieces of food and pureed food. According to the care home staff, peanut butter sandwiches were not listed in his meal plan. The death was not the first at the day care facility. Another patient choked Aug. 9, 2012, and died Sept. 20, 2012.

• A mentally disadvantaged woman who had been homeless was placed in a home in Gwinnett County operated by National Mentor Healthcare on Aug. 22, 2013. According to the investigative report, 37 days later, she was dead. She had fallen in the bathroom and cried out for help. She was found unconscious with her upper body wedged between the toilet and shower. Although she had been in the home for more than a month, no individualized service plan or behavior support plan was in place.

• A 75-year-old man was moved to an RA Healthcare home in Milledgeville on June 1, 2012. He required 24/7 care and assistance with most daily activities. The morning of Sept. 21, 2013, the patient appeared lethargic and couldn’t stand on his own or dress himself. The licensed practical nurse on duty took him to Oconee Regional Hospital. He had been weak the day before, too, and died in the hospital Sept. 29, 2013, of respiratory arrest as a result of bacterial pneumonia and sepsis. An investigative report noted that four staff members had been written up for theft at the home.

• A 61-year-old patient, living in a Macon home operated by DEBI, a privately owned business, was repeatedly seen by a doctor and hospitalized since July 2012 for abdominal pain, nausea, vomiting and weight loss. According to the caregiver, on the day he died he ate most of his breakfast and later seemed lethargic and “sleeping with his eyes rolled back in his head.” At the Medical Center of Central Georgia, he vomited “brown liquid” and was rushed to surgery for a bowel obstruction. He died May 8, 2013, in an operating room. He had lived at Central State until being moved to a home in June 2009. He required 24/7 supervision and assistance with bathing, eating, etc. The man communicated with sounds, gestures and facial expressions. Although bowel movement was a medical issue for him, according to an investigative report, it was inconsistently documented and his records lacked a medication list. The July 2012 hospitalization was not reported to the state, which is a violation of policy. Although numerous problems and policy violations were noted, the only recommendation was training.

How we did it

The Augusta Chronicle began looking into patients of the Georgia Department of Behavioral Health and Developmental Disabilities who died while in community care after learning of the death of 12-year-old Christen Gordon in August 2013.

The investigation began in earnest after the project was selected in 2014 for a National Health Journalism Fellowship, a program at the University of Southern California’s Annenberg School for Communication and Journalism.

The Chronicle used several Open Records Act requests to obtain investigative files on some of the 82 unexplained deaths in 2013 among the department’s patients in community care, which was then focused on just those with developmental disabilities.

The Chronicle received investigative files on 28 patients, but they were heavily redacted and did not contain names or other identifying information. The newspaper then obtained a database of all deaths in Georgia in 2013 – more than 76,000 – and after extensive cleaning of those records was able to use it to identify 24 of those patients. Using other databases, The Chronicle identified family members for a majority of those patients. Many were uninterested in pursuing an investigation into the deaths and some didn’t return e-mails or phone calls.

The Chronicle used other Open Records Act requests to discover that nearly 1,000 patients had died in community care in the past two years and that a majority of the unexpected deaths are among patients with developmental disabilities.

— Sandy Hodson