Nurses Charged in Deaths of 12 Nursing Home Residents

Three nurses have been charged with manslaughter and tampering with evidence in the deaths of 12 nursing home residents. The charges come after a 2 year criminal investigation and more arrests are expected.

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Nurses Charged in Deaths of 12 Nursing Home Residents

On Monday, August 26, 2019, three nurses turned themselves in on arrest warrants for the heat-related deaths of 12 nursing home residents. Eight people died on September 13, 2017, at the Rehabilitation Center at Hollywood Hills, after power-outages following Hurricane Irma caused temperatures to soar inside the facility. Several other residents died in the following weeks. The nursing home’s administrator was also charged. All four individuals are charged with manslaughter and tampering with evidence.

The Details

Hurricane Irma hit south Florida on Sunday, September 10, 2017, and caused extensive damage. A transformer, powering the facility’s air conditioning system, blew when a tree fell. The nursing home’s residents were moved to halls, next to fans and spot coolers in response to rising temperatures inside the facility. There were calls made between nursing home employees, state authorities and Florida Power and Light about the air conditioning failure. According to a report from then Gov. Rick Scott’s office, the state advised facility managers multiple times to call 911 if a situation placing a resident in danger arose. However, it was not until after the nursing home’s first 911 call reporting a person in cardiac arrest, three days later, that assistance arrived.

Timeline

The Sun-Sentinel published an article providing a timeline of events on Wednesday, September 13, based on multiple sources. Victims ranged in age from 57 to 99 years old.

  • 3:00 am- 911 call patient in cardiac arrest
  • 4:00 am- 911 called patient in respiratory distress
  • 4:00 am- Patient with breathing problems taken to hospital
  • 4:20 am- 911 called patient in cardiac arrest
  • 4:30 am to 4:45 am- 911 called, patient in cardiac arrest, with 911 still onsite two more patients go into cardiac arrest
  • 5:00 am- hospital employee checks on nursing home and 3 residents found dead
  • 6:30 am - All residents evacuated

It was determined the deaths of 12 patients was caused by heat exposure. The victims ranged in age from 57 to 99 years old.

No Back-up Generator

The rehabilitation center had previously been cited for failing to maintain an emergency generator. The generator was still not in working order when the hurricane hit. Although fans and portable A/C units were used, an engineering expert testified in a deposition that the A/C units were insufficient and actually made the conditions worse. Temperatures on the second floor possibly reached between 100 F and 110 F degrees, far above the 81 F state law limit. When paramedics arrived, many patients were suffering from fever as high as 109 F, or a heat stroke.

Extensive Investigation

The criminal investigation, spanning two years, continues with additional arrests expected in the future. More than 500 people were interviewed and 1,000 pieces of evidence collected, along with 55 computers. Police also collected and reviewed more than 400 hours of video. Other factors contributing to the tragedy include:

  • Nursing home staff failed to evacuate residents despite being across the street from a fully-functioning hospital.
  • The facility was not on the “high priority” list with Florida Power and Light for unknown reasons
  • Temperatures of residents were not routinely assessed and monitored.
  • Crime scene photos show hand-held gauges recording temperatures inside the facility at 95 and 96 degrees.
  • Video from inside the facility validated a lack of patient assessment and monitoring.
  • The facility reported into a statewide monitoring database 17 times since September 7th, however never requested assistance or report the need for evacuations.
  • Facility advised by the Department of Public Health on Monday, September 10th, to call 911 if they had any reason to believe residents were not safe.

Nurse Behavior

Police officials stated, when announcing the criminal charges, the deaths were all avoidable and due to the behavior and inactivity of facility employees. Officials have also said documentation had been falsified with late added entries to give a false depiction of what actually happened. Questions have also been raised around the employees' preparation for responding during an emergency situation.

  • Nurse One worked at the facility for less than 3 months but had only worked a total of ten days
  • Nurse Two was only scheduled periodically
  • Charge Nurse (in charge of building) had been on the job for about a week

Attorneys for the nursing home reported to the Sun-Sentinel that the facility was fully staffed before and after the hurricane with experienced employees.

A Case of “Waiting on the Cavalry”?

More details will emerge as the criminal investigation continues. Do you think the employees were doing all they could, hanging on until the transformer was repaired? Also, do you think the facility’s administrations lack of preparation contributed to the delayed notification of 911 emergency services?

Additional Information

A Timeline of Unfolding Tragedy at Nursing Home

Hollywood Hills Nursing Home Residents Were Sheltering in Danger During Hurricane Irma Report Finds

Florida Nursing Home Employees Charged With Manslaughter For the Deaths of 12 in Sweltering Facility

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J.Adderton

About J.Adderton, BSN, MSN

(Columnist)

Hello! I am a nurse with 24 years experience. I have enjoyed a diverse career and roles from bedside nursing, leadership, education and now back to bedside. I often write about what I experience, research and question in my own nursing practice.

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Where were the medical director and the owners in all of this? They should be charged too.

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Specializes in Clinical Leadership, Staff Development, Education.
22 minutes ago, egg122 NP said:

Where were the medical director and the owners in all of this? They should be charged too.

Good point, just a failure on so many different levels, including systems that were designed to help. From what I read, once the power company arrived, it took little time to repair the transformer.

Will be interesting to see what (if any) future arrests will be made.

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Specializes in NICU/Neonatal transport.

I definitely agree - anyone the staff spoke to should also be charged and arrested. Yes, the RNs had more knowledge presumably about the patients and medical situation, but unless the RNs were outright lying about conditions ("It's 68 degrees inside and not humid at all") which I highly highly doubt they did, anyone would have known that it was dangerous.

The fact they were so close to a hospital though for evacuation does though make it harder to justify any reason the nurses didn't get help. The whole chain is responsible. edited to add: That even includes administrative staff who were there (secretaries and the like) because it does not take any sort of medical training to know that was dangerous. Those adults were vulnerable. They deserve protection.

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That is why I don't go to work for several days after a disaster because you will encounter a lot of worst case scenario in the job then in the end, you'll be liable for what will happen to the patients if something wrong comes along. The nurses who went to work that day were real heroes because, they choose to work while others can't do it and help out to lessen any casualties that may occur in that particular crucial day after the disaster. Yes, they can send all the patients to the hospital which is next door but can the hospital accept them right away even though there is no paper works the nurses has to make. Even for one patient, it will take time to submit documentations so that these patient will be processed to the hospital when they get there. The hospital won't accept any patient if they don't have the H&P, labs, face sheets, med recon, progress notes, doctor's order, transfer sheet etc that will be submitted to the hospital. In that day alone, there were a dozen of patients that needed care while there were only 4 nurses to prepare them for transfer to hospital. Would they be able to process the patients with limited manpower or resources during those times that calamity strike the area with it's consequences were happening beyond their control. I repeat, the nurses and people who worked that day were real heroes because they were there in that particular day to assist and help out to those in needs. They were there to call different departments in the government so that they can head out to their facility because elderly were sickened and dying brought about the current disaster at that time. If it weren't for their heroic acts, more patients could have been dead for several days without the public knowing about it. Therefore, the public could be judge mental in whatever ways they can think about but were the public there to look after the vulnerable patients in those calamity days. No there weren't but look at the nurses who worked tirelessly, they didn't abandon them but they were the last men or women standing so that emergency care could be initiated. I just hope that people would reach out during the disaster or catastrophic time instead of blaming others after the fact.

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This is crap and these overinflated charges seem to be an attempt to placate the family and place blame. This seems more of an administrative issue than a nursing / clinical issue.

Where was the doctor?

Was he / she called? What was the doctors recommendation?

What was the recommendation of administration in this matter? Did the nurses follow through on this recommendation?

Events like this are quite eye opening , and unfortunately they serve to keep great clinical staff out of nursing homes - which are notorious for being under staffed, LITIGIOUS , limited resources, and high nurse to patient ratios.

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10 hours ago, egg122 NP said:

Where were the medical director and the owners in all of this? They should be charged too.

What about the patient families. Sometimes it seems like the patients families don't want any responsibility except to hire an attorney and collect a check when something goes wrong. Why didn't family members pick up their loved ones? I know I would have.

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I am so tired of the State Attorneys criminally prosecuting people who show up! If you are a deadbeat employee who disappears when disaster strikes then you live to see another day. Lets not forget, the employees who showed up were working under the same conditions that the residents were in, the residents who had family members were not check on or checked out by their family members. According to the article their were 4 nurses and over 140 patients that's a ratio of 35:1 in a state that refuses to legislate safe nursing ratios. Dear Mr. States Attorney - Maybe next time no nurses will show up to care for the patients!

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Also where is the Florida Nursing Board on this issue. Do they refuse to protect us or provide any legislative protection bills for healthcare workers who are caught up in disaster situations? Are we just out there with our hineys hanging out when disaster strikes? The hospital is not going to just accept people because they are too hot. How do 4 nurses evacuate 140 residents efficiently? If the State of Florida does not support healthcare workers than maybe we shouldn't work in that State! As far as I am concerned it is not safe to practice nursing in the State of Florida. No safe patient/nurse ratios, no responsibility of facility owners, if you show up to help then you can and will be prosecuted!

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Specializes in Medsurg.

Maybe I'm just tired from working my night shift....but that sounds like those nurses were set up for failure. Hell the charge nurse only been there a week. Leadership sounds like it was lacking there. This is why I'm very apprehensive when it comes to environments that can put my license in danger.

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1 hour ago, makingstrides said:

This is crap and these overinflated charges seem to be an attempt to placate the family and place blame. This seems more of an administrative issue than a nursing / clinical issue.

Where was the doctor?

Was he / she called? What was the doctors recommendation?

What was the recommendation of administration in this matter? Did the nurses follow through on this recommendation?

Events like this are quite eye opening , and unfortunately they serve to keep great clinical staff out of nursing homes - which are notorious for being under staffed, LITIGIOUS , limited resources, and high nurse to patient ratios.

Most normal people and minimally competent people would call 911 BEFORE their patients cooked to death.

40 minutes ago, Snatchedwig said:

Maybe I'm just tired from working my night shift....but that sounds like those nurses were set up for failure. Hell the charge nurse only been there a week. Leadership sounds like it was lacking there. This is why I'm very apprehensive when it comes to environments that can put my license in danger.

Definitely a perfect storm, no pun intended. It should serve to remind us that no matter what, we are personally responsible for the safety of our patients. If they are cooking to death we need to take action.

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Specializes in RHIT with a crap load of medical experience..

One of our facilities near coastline was evacuated to our facility because of potential flooding. We secured trucks for equipment, ambulances and buses for residents. Our facility was packed with two facilities in one, staff from the other facility, maintenance, administrator, nurses, CNA and dietary and our staff. I was very impressed. It was handled professionally and privacy of residents. With systems, checks and balances in place for certified beds and feds' survey every year, this should not have happened. An evacuation plan should have already been in place. I can't believe that this went as long as it did with this level of incompetency and substandard facility.

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