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.”