Neglected: Even when staffs cause patient deaths, Florida nursing homes face few penalties
When 81-year-old Dolly Moore became lethargic and lost her appetite, nurses at Parklands Rehabilitation & Nursing Center in Gainesville said there was nothing wrong.
Her children were told to accept that their mother’s worsening dementia triggered the symptoms. Moore was not ill. Her lab results were normal, nurses insisted.
But they were wrong. Moore's lab results showed a severe infection raging in her body.
Parklands' nurses never reported the abnormal lab results to a doctor and didn’t treat the condition, a state investigation found. The infection spread, swelled her head to the size of a basketball and killed her on Oct. 1, 2014.
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“The hospital told us it was the worst case of neglect they’ve ever seen,” said Connie Thames, Moore’s daughter.
Florida’s Department of Children and Families found that Moore died because of the nursing home's neglect. Those findings by the agency that investigates elder abuse and neglect were forwarded to Florida's Agency for Health Care Administration, the department that oversees the state’s 687 nursing homes.
Despite evidence of neglect leading to Moore’s death, AHCA took no action against Parklands. The agency didn’t cite the home for violations, impose fines or revoke its license.
It’s not even clear AHCA investigated Moore's death after a separate state agency found evidence of neglect. AHCA's inspection reports don’t reference Moore’s case.
As the state agency responsible for making sure nursing homes are safe, AHCA rarely issues fines even when another state agency reports neglect or mistreatment by a home’s staff, a USA TODAY NETWORK - FLORIDA investigation found.
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And there is often no evidence AHCA even investigates those deaths, raising questions about whether nursing homes are held accountable when patients die from mistreatment.
“The industry complains about how punitive and horrible the system is and, in reality, almost nothing happens to any of them, no matter how bad the situation,” said Toby Edelman, senior policy attorney with the nonprofit Center for Medicare Advocacy in Connecticut.
Elliot Williams, Parklands' administrator, declined to comment on Moore's death.
As part of its investigation, the Network reviewed 54 patient deaths verified by the Department of Children and Families as resulting from nursing home neglect or mistreatment from 2013 through 2017. The deaths were detailed in reports on 43 cases, one involving multiple deaths. The state-verified findings of abuse and neglect by nursing home staff were sent to AHCA, which has the authority to take action against the homes.
Those deaths included a 91-year-old Sarasota woman who died vomiting her own fecal matter; an 87-year-old woman in Boynton Beach who investigators said died after staff crushed her ribs and punctured her lung; and an 84-year-old Jacksonville man who died from an infection that spread from his untreated, rotting genitals.
Among the USA TODAY NETWORK - FLORIDA's findings:
» In about three-quarters of the verified cases, or 32 of 43, AHCA took no action — no fine or penalty — against nursing homes after the state determined staff caused or contributed to a patient’s death.
» In nearly two-thirds of the cases, there’s no evidence AHCA investigated the deaths or the nursing home's role. The agency admits it failed to investigate 10 cases, and in 18 others it's not clear AHCA investigated because the deaths are not noted in inspection records.
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» State reports show the neglect and mistreatment identified in the nursing home patients’ deaths often were not isolated occurrences and AHCA knew it. In at least 25 of the 43 cases, AHCA cited the nursing homes for similar problems.
When presented with the USA TODAY NETWORK - FLORIDA findings, AHCA spokeswoman Mallory McManus acknowledged the agency’s inadequate response to the deaths.
“We are always working to improve our processes and have identified and initiated changes,” McManus wrote in an email. "This includes working with DCF to ensure that there is no wrong door for reporting findings related to a nursing home death."
To ensure state death reviews are handled properly, McManus said the agency will improve coordination and communication with others investigating neglect and abuse cases. AHCA will implement an independent review of all nursing home deaths verified by the state as neglect or mistreatment and create “a state-level process to address investigation result,” she said.
Turning a blind eye
As the nation watched last fall, AHCA took swift action against a Broward County nursing home where 12 people died in sweltering heat after Hurricane Irma knocked out the air conditioning.
Within days, AHCA banned the Rehabilitation Center at Hollywood Hills from admitting new patients and stopped its Medicaid payments.
Ten days after the storm hit, AHCA suspended the home’s license and eventually shuttered it — an impressive display of the agency’s power to protect patients from dangerous conditions at a nursing home. The facility's owners have challenged the state action and are denying that staff failed to act properly.
But such quick and decisive action by AHCA is rare, the Network’s investigation found.
The tragedy at Hollywood Hills is one of the 43 cases in the five-year period reviewed by USA TODAY NETWORK - FLORIDA in which the state concluded nursing home staff mistreatment or neglect led to patient deaths.
During the same period, the state found credible evidence of mistreatment or neglect at nursing homes in 56 other deaths but not clear and convincing evidence, and it designated those as unsubstantiated, records show. The details related to those cases are not made public under a Florida law that provides for release of state death reviews only in verified cases.
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In most verified cases, AHCA didn't act. The agency cited the nursing home for violations in 15 of the 43 death cases, or only about a third of the deaths, according to state inspection records.
AHCA imposed fines in only 11 of the cases, including the Hollywood Hills home, which has been shuttered, state records show.
Most of the time, there is no evidence that AHCA investigated deaths after the state's reviews found mistreatment or neglect by the nursing home, the Network found.
After being presented with the Network's finding, AHCA acknowledged it did not investigate 10 of the deaths, despite receiving state reports detailing nursing home mistreatment and neglect.
One of those cases was the September 2015 death of Stacie O’Loughlin. The 38-year-old mother of four died from a septic infection at Governors Creek Health and Rehabilitation in Green Cove Springs near Jacksonville.
O’Loughlin, who had been diagnosed with multiple sclerosis at 20, was in the nursing home for short-term rehabilitation. While there, she developed an infection that went untreated for so long that she began crying out in pain.
For days, the nursing home staff ignored O'Loughlin's symptoms of a severe infection — elevated temperature, difficulty breathing, tea-colored urine, reports said.
When she was taken to the hospital it was too late, the state death review found. She died a week later.
Jennifer Trapp, spokeswoman for Consulate Health Care, the company that owns Governors Creek, acknowledged receiving a Network email requesting comment about the case but did not provide a response.
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DCF faulted the nursing home for neglecting O'Loughlin and sent the findings to AHCA, which never followed up.
“What’s the point of having DCF (investigate) if no one is doing anything?” asked Shaylene Wallace, O’Loughlin’s sister.
In 18 cases, AHCA claims it inspected the nursing homes in response to the deaths. However, the agency's inspection reports make no mention of the deaths, and when pressed officials provided no evidence.
That was the case in the death of John Gentile. The 71-year-old had been battling nasal and mouth cancer for years, and he was admitted to Palm Garden of Aventura for rehabilitation on July 1, 2017, to learn how to live with a tracheostomy tube.
Early the next day, struggling for breath and unable to speak, Gentile tried for more than 20 minutes to call for help. At 2:45 a.m., Gentile sent a text to his daughter in Utah — "911" — and then immediately called her. A minute later she called the nursing home, according to her phone records.
Kristin Hooten, Gentile's daughter, tried repeatedly over the next 11 minutes to convince the nursing home to call an ambulance, records show.
When Miami-Dade Fire Rescue finally arrived, medics told the nursing home staff not to disconnect Gentile from his ventilator because they didn’t have a portable unit to transport him. The staff disconnected Gentile anyway, telling medics, “You have to take him,” according to the medical examiner’s report.
Starved of oxygen, Gentile went into cardiac arrest and died shortly after he arrived at the hospital a mile away.
“My dad, he died terrified,” Hooten said in the interview. “And that is going to haunt me for the rest of my life.”
The nursing home’s staff neglected Gentile and didn’t properly supervise him leading up to his death, the state review concluded.
AHCA's inspection records do not reference Gentile's death, although the agency claims the incident was reviewed more than two weeks later. The home was not cited for any problems related to the death.
Kirsten Ullman, a lawyer representing Palm Garden of Aventura, said that "as much as we would love to tell the story of our caregivers who do amazing works every day," privacy rules prohibited her from commenting.
McManus, AHCA’s spokeswoman, said even in cases where a patient dies due to staff neglect, a nursing home may avoid being cited if inspectors determine the problem was fixed prior to the inspection. That means that even if the nursing home’s staff contributed to the death, AHCA maintains no public record of the staff’s failures, no record of the death and no history of the home's neglect.
With the exception of those at Hollywood Hills and a few others, most of the nursing home deaths reviewed by the Network that involve neglect or mistreatment have gone unnoticed by the public and the media.
“What we’ve seen is that AHCA rarely takes action and punishes these nursing homes,” said Greg Yaffa, Hooten’s lawyer. “And by turning a blind eye, what AHCA is doing is enabling this action.”
AHCA refused to make any agency leaders available to discuss the death cases. However, AHCA Secretary Justin Senior has said the agency is focused less on punishing nursing homes and imposing fines, and more on bringing them into compliance.
“We are required by Florida law to take the least invasive, least intrusive licensure action that we can take under the circumstances,” Senior said in an interview earlier this year.
Florida law promotes penalties as "secondary to the primary goal of attaining compliance." But the statute states it applies only to minor violations and not those that result in "physical harm to a person or adversely affect the public health, safety or welfare, or create a significant threat of such harm."
USA TODAY NETWORK - FLORIDA has reported on how AHCA allows the state's worst nursing homes to remain open despite repeatedly failing to meet state and federal standards; imposes small fines and rarely uses the sanctions available to penalize poor performers; and allows the state's largest nursing home chain to thrive despite a history of poor patient care.
See more: Florida's worst nursing homes left open despite history of poor care, deaths
Repeat offenders
When a nursing staff's actions lead to the death of a patient, it’s usually not the first time the home has been cited for similar acts, state records show.
USA TODAY NETWORK - FLORIDA reviewed a nursing home's AHCA inspection reports for three years prior to the patient's death and every inspection report after the death. In at least 25 cases, AHCA cited the nursing homes for similar problems either before or after a patient’s death and allowed the problems to continue with little or no consequences, the records show.
That was the case at Consulate Health Care of Jacksonville, where York Spratling, 84, died in February 2017 after surgery to remove dead tissue from his gangrenous genitals.
Spratling wasn't being bathed at the nursing home. And even though staff could smell the rot when stepping into his room, the doctor wasn’t told about the wounds or severe infection for five days, the state's death review notes.
“Everything was about to fall off, it was so rotten,” said Spratling’s brother, Obie.
The nursing home's staff neglected Spratling by failing to get him treatment and not reporting his condition to a doctor, the state review found.
There is no evidence AHCA investigated the death. When asked how the agency responded to the death, AHCA cited an inspection conducted two months later that didn't reference the incident. The agency never cited the nursing home for any violations related to Spratling’s death.
There were warning signs in Consulate’s previous inspection reports.
AHCA cited the home with violations three times in the year before Spratling’s death for not having enough staff to give patients regular showers or personal hygiene care.
“I have not had a shower in I don’t know how long,” an unnamed patient told AHCA inspectors in September 2016, five months before Spratling died, according to an inspection report.
The complaints of neglect and inadequate staffing continued even after Spratling’s death. Eight months later, AHCA again cited the home for understaffing, with one patient telling inspectors, “I wallow around in this bed in my own piss.”
Consulate Health Care did not respond to requests seeking comment.
Other homes, too, showed a pattern of problems, harbingers of fatal errors, including: failure to follow doctors orders, not conducting thorough investigations after untimely deaths, and failure to prevent patients from falling. Few of the violations resulted in fines or penalties.
Few fines, low fines
When AHCA does take action against a nursing home after a death caused by staff mistreatment or neglect, fines are often small.
The median fine imposed in the 11 death cases in which AHCA identified violations was $65,162, according to a Network analysis of penalties. Four of the fines were under $20,000.
“That just shows the facilities they don’t have to worry about the enforcement of AHCA,” said Brian Lee, former head of the state’s Long-Term Care Ombudsman program in the Department of Elder Affairs, who now heads the nonprofit Families for Better Care in Austin, Texas.
“They may get hit, they may not,” Lee said. “But it’s more cost-effective for them to not provide good care. They make more money that way.”
In two cases, the nursing homes paid six-figure fines to the state and federal governments: $380,470 by Boulevard Rehabilitation Center in Boynton Beach after staff broke an 87-year-old patient's ribs and punctured her lung in 2017; and $106,865 by The Aristocrat, now known as Solaris Senior Living North Naples, after a 90-year-old patient was left out in the sun and died in 2014.
Boulevard's administrator IIene Berkon-Cardello did not respond to requests for comment left on her voicemail. Jennifer Iavarone, the administrator at Solaris in North Naples, declined to comment other than to say the death happened under a previous owner.
AHCA also has recommended a $37,500 fine for the Rehabilitation Center at Hollywood Hills on top of a $83,860 fine from the federal government for violations resulting in the 12 deaths after Irma.
Michele Ozkan doesn't believe a $15,337 fine was sufficient punishment for Tarpon Point Nursing and Rehabilitation Center in Sarasota after the 2014 death of her mother, Stella Budich.
Budich, 91, a former union activist, suffered a massive bowel blockage that ruptured her intestine and left her vomiting a coffee-brown mix of blood, bile and fecal matter, according to a Sarasota County Sheriff’s Office report.
“How does your mother, who fights for the rights of people, wind up dying vomiting her own fecal matter?” Ozkan asked.
The bowel impaction developed over a period of months, according to the Sheriff’s Office report. The nursing staff should have known, Ozkan said. “That was their job to know.”
AHCA initially failed to find any wrongdoing on the nursing home’s part, but it reopened the case and cited the home for a “systematic problem” documenting patients’ bowel movements.
The nursing home has denied responsibility for Budich's death, according to its responses submitted in court to a lawsuit filed by her family.
“They can do what they want to people, cause their deaths, and nothing happens,” Ozkan said. “Somebody has to be held accountable.”
Contact the reporters:
Ryan Mills at Ryan.Mills@naplesnews.com
Melanie Payne at mpayne@gannett.com