Nurses Charged in Deaths of 12 Nursing Home Residents

J.Adderton, BSN, MSN

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