USA TODAY
Published 8:02 a.m. ET
May 4, 2019
Jim Ferguson wanted answers
How was his 91-year-old
father, who served in the U.S. Navy in World War II, fatally
injured in a Veterans Affairs nursing home, the institution Ferguson
had entrusted to care for him?
Huddled around a computer
monitor with managers at the VA in Des Moines, Iowa, Ferguson watched a
hallway surveillance video that depicted a chilling blow to his
father's head.
“I lost it,” Ferguson told USA
TODAY. “I broke down.”
In the video, James “Milt” Ferguson
Sr., who had dementia and was legally blind, appears confused.
He opens a hallway door, rolls his wheelchair into another resident’s
room, then wheels back out. No staff members are visible. He circles around and
heads back into the room.
Halfway through the door, his chair
flips over backwards. Milt Ferguson crashes to the floor, landing
on the back of his head. Ferguson said he was told the chair was
pushed over by the resident in the room, who can't be seen in the video.
As staff members rush to assist him, Ferguson is able to turn over and sit
up, but the impact causes a massive brain bleed that will
kill him within days.
What later would turn the son’s
despair into outrage was what he learned about events leading up to his father
wheeling around unsupervised last December, and what happened after he smashed
into the floor.
“It’s like my dad died at their
hands,” Ferguson said.
A surveillance camera captured
footage of James Ferguson Sr.’s fatal injury at a Veterans Affairs nursing
home. Caution: footage may be disturbing. USA TODAY
Serious problems with resident care
have occurred in many VA nursing homes across the nation, including the one
where Ferguson was being cared for.
USA TODAY reported in March that
inspections by a private contractor hired by the VA found deficiencies
that caused "actual harm" to
veterans at more than half of the 99 VA nursing homes reviewed.
The inspections found inadequate supervision or hazardous conditions at 53 of
them.
In Des Moines – which
received the lowest one star out of five in the VA's own ratings,
based on surprise inspections – inspectors found managers did not ensure
staff treated residents with dignity or followed basic infection-control
and prevention measures.
The story of what happened to James
Ferguson in Des Moines provides a deeper picture of the care one elderly
veteran received. Medical records provided to USA TODAY by his son and legal
guardian outline what specialists say was a concerning series of decisions by
VA staff, before and after his deadly head injury.
Nine days before, VA caregivers
determined Ferguson was a danger to himself and others because his
dementia caused him to wander around, agitated. They had him on continuous
one-on-one observation with an aide, but took him off the strict monitoring
when he entered the VA nursing home. There, staff didn't reinstate the
heightened observation, despite his repeatedly straying dangerously into
other residents' rooms.
After his injury, staff put him back
in his wheelchair but did not report the incident to a supervisor for
40 minutes, the records and surveillance video indicate. Ferguson wasn't
transported to an emergency room for two hours after that. Then, it
took 2½ hours more to send him to a trauma hospital. The time stamp on the
video showed the fall occurred at 3:49 p.m. and it wasn't until just
before 9 p.m. that Ferguson was transported to the trauma facility.
'A
disaster waiting to happen'
Specialists who reviewed Ferguson's
medical records at the request of USA TODAY expressed concern
about the quality of his care.
"It was definitely a disaster
waiting to happen, and it did," said Robyn Grant, director of public
policy and advocacy at The National Consumer Voice for Quality Long-Term
Care, a Washington-based nonprofit advocacy organization.
"I just am really struck by the
predictability with his repeated episodes of going into other people's
rooms," she said. "They should have had some intervention so they
could provide him with adequate supervision and address the wandering."
Grant said the length of time it
took afterward to adequately evaluate and diagnose the severity of his injury
and get him to a trauma facility also raises questions. "What was
happening there, in terms of those delays?" she said.
VA nursing homes: Feds find 'blatant disregard' for
veteran safety
Richard Mollot, executive director
since 2005 of the Long Term Care Community Coalition, a New York City-based
nonprofit advocate of nursing home care improvement, said the shortfalls
indicate there was "very likely" a lack of skilled or adequately
trained staff to meet his needs.
"The point of being in that
environment is that you have skilled nursing care and monitoring," he
said.
Mollot said the reporting delay is
particularly concerning. "How often does this happen that no one's looking
at? That's what is so upsetting."
'All
staff acted properly'
A spokesman for the Des Moines VA,
Timothy Hippen, said in a statement that a review after the "untimely
death" concluded "all staff acted properly."
"Any time an unexpected death
occurs, VA Central Iowa Health Care System reviews its policies and procedures
to see if changes are warranted," he said. "We did that here, finding
that all staff acted properly."
In response to questions about the
case, national VA spokesman Curt Cashour accused USA TODAY of focusing on
"isolated complaints" and "cherry-picking the experiences of a
handful of veterans to create the impression of a broad problem."
Cashour maintained that, overall, VA
nursing homes "compare closely" with non-VA facilities. More
than 40,000 veterans rely on care at the agency’s 134 nursing facilities each
year.
USA TODAY reported last year that
about 70% of VA nursing homes scored
worse than non-VA nursing homes on a majority of quality indicators
tracked by the agency, which include rates of infection, serious pain and bed
sores.
Hippen declined to respond to
detailed questions about Ferguson's case.
"We will not be addressing the
specifics of this case publicly, but we have been in direct contact with the
veteran’s family to discuss their concerns," he said.
Jim Ferguson said he remains upset
even though VA officials shared the surveillance video with him and said
they were sorry about what happened to his father.
He wants VA staff held accountable.
He wants to make sure policies are in place so it doesn't happen to anyone
else.
“No one should live their life like
that and have what happened to him in the end,” he said. “I want this to be the
last person this happens to.”
A
gambler called ‘booger’
Even as his dementia worsened, Milt
Ferguson flashed glimmers of his younger self.
The former deckhand on the heavy
cruiser U.S.S. Pensacola was affectionately known as “booger” at
the Des Moines Register, where he worked bundling newspapers for 23 years
before retiring in 1995. He loved to play the slots and the horses.
On a note in his medical record, a
nurse practitioner wrote: “Patient laughs when his nickname is mentioned.” Jim
Ferguson had come for a visit that day, as he did most days. “He was smiling
and appeared to be enjoying his son’s company,” the medical record said.
The decision to place him in a
nursing home had been a gut-wrenching one, Ferguson said. He had moved in
with his parents and cared for them for three years. But in April 2018 his
mother died. He said a VA social worker told him his father needed more
intensive, round-the-clock care and supervision.
“They made it sound like, well, if
he got hurt, I could be charged with a crime,” Ferguson said. “So that’s when I
decided to place him in a nursing home.”
‘His
dementia was acting up’
Ferguson moved his father to
Bishop Drumm Retirement Center, a private facility just outside Des Moines,
where his mother worked as a nursing assistant in the Alzheimer’s
unit for more than 20 years before retiring.
The center took in Milt Ferguson
last August. But three months later, his condition worsened.
"The day before Thanksgiving, I
got a call from Bishop Drumm – his dementia was acting up," his son said.
He hit two staff members, was
“agitated all day” and was “wandering into other residents room(s),
causing distress,” a nurse later noted in his medical record. “He is
generally ‘sweet’ so this is a departure from his usual behavior.”
Ferguson was taken by ambulance to
the Des Moines VA Medical Center, where he was admitted to the acute psychiatry
ward. He was put on one-on-one observation with a sitter – an
aide tasked with intervening if he lashed out or tried to stray into other
patients’ rooms.
They adjusted his medications, and,
after a few aggressive outbursts, he appeared calm enough after three weeks to
transfer into the VA nursing home on the medical center’s campus.
But there was a catch, a psychiatric
nurse wrote in his record: "Veterans are not put on sitter status over
there."
‘Help
me, help me’
After a 22-hour trial period without
a sitter, Milt Ferguson moved in to the VA nursing home.
Problems began within hours.
He hardly slept, he hallucinated, he
called out "help me, help me" over and over again. He was agitated
and again, he "wandered into and out of peers rooms" day after
day, nursing staff wrote in his record.
They gave him medication. Sometimes
he calmed down. Sometimes he didn’t.
A psychiatrist was managing his case
remotely. According to public records, the doctor worked at a VA facility
a few hours away in Lincoln, Nebraska. Through virtual appointments, the
psychiatrist advised changes to Ferguson's medication.
On December 19, a week after
Ferguson moved in, nursing home staff noted he was still restless and
anxious, pacing and screaming and yelling. His care team – psychiatrist,
primary care doctor, nursing staff and social workers – met to discuss the
case.
The psychiatrist said a review of
his records showed "increased confusion with wandering" during
the past week. The doctor prescribed higher dosages of a mood-stabilizing
drug and a sedative. There was no discussion of closer supervision or
reinstatement of one-on-one observation, the records show.
“Will ask RN to contact this MD in one
week with update,” the psychiatrist wrote.
By then, Ferguson would be
dead.
‘A
golf ball-sized lump’
On December 20, when two aides
rushed to help Milt Ferguson, his head on the floor and legs crumpled to the
side, the time stamp on the hallway surveillance video reads 3:49 p.m. But
in a report filled out an hour later, a nurse recorded the time of the accident
as 4:30 p.m.
His records do not indicate
what the staff did with Ferguson during the 41 minutes in
between, aside from putting him back in his wheelchair.
By that time, he had a “golf
ball-sized lump on the back of his head.” The nurse notified the manager on
duty, a nurse practitioner, who wrote at 5:06 p.m. that he had
ordered an immediate CT scan of his head.
That didn’t happen until about 6:30
p.m., when Ferguson arrived in the emergency department of the medical
center on the Des Moines VA campus, on a bed wheeled by a nursing home aide.
The aide said Ferguson had earlier been taken for a CT scan but was
uncooperative.
An emergency room doctor quickly had
a sedative administered and the scan was completed. By that point, the World
War II veteran had a “large bleed” in the back right side of his brain that was
so acute, the CT report says his brain had shifted to the left inside
his skull.
Sent
'to scanning’
The doctor notified MercyOne Des
Moines Medical Center, a trauma hospital, at 7 p.m. For nearly two hours, the
doctor tried to keep Ferguson comfortable and his blood pressure under control
until an ambulance arrived and took Ferguson to Mercy at 8:55 p.m.
The doctor also kept calling
Ferguson’s son, leaving voicemails.
Jim Ferguson with his father James
"Milt" Ferguson. (Photo: Family Photo)
But Jim Ferguson had himself been
admitted to a hospital and had provided the VA nursing home with a consent form
authorizing staff to contact a close friend if anything happened to his father.
That form had been sent "to scanning” that morning.
When Jim Ferguson retrieved all the
voicemails, he rushed to Mercy the next morning.
"He was not responsive. He
was laying on his bed, making this horrible noise as they sucked saliva
out of his mouth," he said. "I never even got to say any last words
to my dad."
He died the next day.
Specialists who reviewed the case at
the request of USA TODAY singled out multiple shortfalls in his care at
the VA that may have affected the outcome.
Grant, the policy director at The
National Consumer Voice for Quality Long-Term Care, said the 22-hour trial
of having no sitter was "not enough time to establish how he was
doing."
When he then acted out day after
day, in agitation and confusion, they should not have allowed him to wander
into other residents' rooms, she said. Such situations can cause the other
residents to lash out in fear or distress and "lead to an altercation or
violence or striking out."
"One would argue that could
have been prevented," she said. "There should have been
somebody, somewhere who could have seen that this happened and – particularly
when he wheeled himself – to have gone in and intervened, 'Let me
help you, let's go to your room.'"
Mollot, the executive director at
the Long Term Care Community Coalition, said meeting the standards of care
means staff identifies risks and needs and ways to meet them and mitigate them
and then does so consistently.
"This is exactly the kind of
thing that happens when those standards are not followed," he
said.
'A
safe place'
The spokesman for the Des Moines VA,
while declining to answer detailed questions about what happened, said that
in general, "caring for nursing home residents involves balancing
patients’ independence with the need for supervision, as appropriate."
"While tight scrutiny and
strict limits on residents’ activities and freedom of movement could possibly
lower the risk for adverse events, it would also severely degrade patients’
quality of life, which is precisely what we are trying to preserve for as long
as possible," he said.
Jim Ferguson still has his
father’s wheelchair in the garage. He keeps the sweatshirt his father was
wearing when he last used the chair. Ferguson has retained
a lawyer, Brad Biren, to help him figure out next steps and how to hold
the VA accountable.
“Somebody didn’t watch my dad and
let him die,” he said. “It’s supposed to be a safe place.”
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