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.

Updated:  

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

Specializes in Surgical Specialty Clinic - Ambulatory Care.
2 hours ago, Gina s, RN said:

I don’t think they could have monitored them alone. I made an assumption (could be completely wrong) that they weren’t the only 3 working, rather 3 nurses were charged.

My experience with SNFs and/or assisted livings is that the ratio of nurse to patient ratios are often 1:30-40 with some CNAs. So 3-4 nurses may well be all the nursing staff that was at the facility.

If this was a SNF the patient’s are far less stable than those at an assisted living and often have A LOT of care needs. Bed bound, wheelchair bound, peritoneal dialysis, wound care, severe dementia, etc. Assisted Livings are more like what nursing homes were 20-30 years ago, elderly people who need help with medications, minimal assistance dressing, bathing, and meals, etc.

I have no clue why one of these nurses didn’t call 911 within the 3 days. Were these 3 nurses the only ones there all 3 days (It was storm, were other staff coming to work?). Just way to many gaps in the article for me to make a call all the way. Did the nurse reach out to upper management with concerns, was she so overwhelmed and suffering from heath exhaustion his/her self to think through things appropriately? So many questions. But my gut goes the one responsible for these deaths is the person who didn’t make sure the back up generator got repaired/replaced (and/or the person who never approved the budget requests to get it fixed) when they got cited for it during an inspection before this storm took out the electricity.

Being that this was a nursing home, it is likely that these were LPN's. Not that that gives them any more excuse but just from my experience in LTC they were probably being directed by higher level staff to "wait it out" or something along those lines.

This is a horrible tragedy. I feel for the family members who have lost loved ones, and also wonder if anyone had come and checked on their family.

While these nurses should have reported what was going on, I am sure that if they were taking orders they are going to tell all now that they have confessed so the DON, Administrator, Medical Director and all others above these nurses better be prepared!

Specializes in PACU, Stepdown, Trauma.

Good grief, why wouldn't you call 911 if your residents were stuck in 100+ degree temperatures for 3+ days? It's basic common sense and human decency, which isn't something that you need a nursing license to possess.

However, this isn't only on the nurses - this is also on the DON, administrator, medical director, etc. Sounds like lots of balls were dropped and unfortunately innocent people paid the ultimate price.

Look at how quickly things happened once the emergency authorities were finally alerted on the timeline provided. People never need have died if only one staff member had reached out for help earlier.

Specializes in ED, PACU, CM.

Although three nurses and the administrator where charged, there seems to be plenty of blame to go around here. It is unclear just how much staff was present. The nursing home states they were fully staffed before and after the hurricane. I took this to mean that although there may have been just three nurses present, they still had CNAs and other staff onsite. The administrator and the director of nursing should have been onsite as well. They both came in once patients started dying. Why not earlier? During disasters staff roles may have to expand. Did they have dietary or other staff round on patients and offer residents more water? Did they identify higher risk patients and have them checked on more frequently? These things help with early recognition of patient decline so that help can be summoned before they are in crisis or code. The corporate office/owners are also at fault for not providing necessary equipment and good contingency planning. Hurricanes in Florida are hardly unheard of. This nursing facility needed a generator powerful enough to keep their A/C running. It is well established that the elderly are more susceptible to heat-related illness.

In regards to the person who mentioned paperwork necessary to get a patient to the ER: that kind of thinking causes delays that get people killed. I worked in the ER for many years, and we never refused or turned away a nursing home patient over paperwork. Ultimately, nurses are responsible for the care of their patients. In a situation like this it is best to err on the side of caution and simply call 911 if there is suspicion of patient deterioration. Whatever difficulties the hospital experiences is not your problem, and more importantly, not your patient's problem either.

Specializes in Psych.

I know California has that mandated ratio for each nurse. They should do that for all states. Nurses are really held on so much responsibility sometimes too much than what they should.

1 hour ago, Devnation said:

I worked in the ER for many years, and we never refused or turned away a nursing home patient over paperwork.

No, but I’m pretty sure you would not have taken 140 patients in one fell swoop either. We had an ECF with a Norovirus epidemic who tried to send us 40 pooping and puking senior citizens all at once. We refused to take them all and insisted that they divide them between us and the 8 other hospitals in our city. We got 6 which was doable and safe for all involved.

Specializes in Critical Care.

In a State of Emergency following a natural disaster, 911 isn't who you call to report a need to evacuate, they'll redirect you to the relevant incident command center. The nursing home reportedly made multiple calls to both the State disaster response and even the governor, and were told to hang-tight until they're able to restore power.

A nursing home in this situation can't simply ship all their residents to a hospital, particularly one that by reporting at the time was severely overburdened already, it's either the State disaster management or FEMA that can approve an evacuation and direct the hospital to take x number of residents.

Reportedly, the majority of these patients who didn't survive were there as hospice patients, it's certainly unfortunate that it wasn't possible to keep these patients more comfortable, but it seems a bit silly to say that because actively dying patients didn't survive a natural disaster, it must be because the nurses committed crimes.

Specializes in retired LTC.

This incident has me very concerned - long before this article was posted here on the 'yellow' side of AN, I made an entry over on the 'blue'side. It was late night 'breaking news' on TV and I was just blown away.

I truly believe that there's much more to this story. A couple of PPs' entries refer to the so few minimal staff present. I wonder if they were mandated/'strong-armed' by Admin/management into being forcibly detained at the facility? With some vague threat about 'abandoning pts'? Were they the 'disaster plan emergency team 1' designees?

Somethings I have since read refer to Florida P&L not showing up. And some State DOH person visiting the facility. THAT needs to be investigated. Just FYI - it prob would be IMPOSSIBLE for families to come and pick up the facility's pts (road conditions, pt acuities, aged/elderly sig others, etc).

I did work at one LTC/NH where we accepted multiple pts from another local NH who had to 'emergency evacuate'. In such an emergency any EMPTY beds avail anywhere can be 'loaned out'. As I was leaving, those other NH pts rolled in, one behind the other. They came with their MARS, TARS, avail meds and charts. And a small bag each of some personal belongings. Our dietary/ kitchen just made some extra breakfasts and I remember our staff catching some fast VS and checking for diabetic fingersticks. Also quick body checks. All the right Admin and dept staff higher-upper staff were notified.

Like PP Henrylee9, it occurred easily enough with a 'controlled craziness'. That hospital across the street prob COULD HAVE accommodated. And I also think it's a federal mandate that facilities have an 'emergency disaster plan' in place with staff training. Or was it just an old dusty manual on some shelf in the LNHA's office?

So like some posters have said a lot of folk seemed to have dropped the ball. Again it's terribly sad that the nurses are being nailed. That REALLY was my first thought when I heard the TV news. While the nurses were identified as new' to the NH, they prob were experienced nurses. Was anyone 'agency? I hope they have STRONG nurse/lawyers for their counsel.

Hell, I'd even donate to their cause.

Specializes in OR, Nursing Professional Development.
3 hours ago, The0Walrus said:

I know California has that mandated ratio for each nurse. They should do that for all states. Nurses are really held on so much responsibility sometimes too much than what they should.

CA only mandates ratios for hospitals. It does not cover non-acute settings.

Specializes in Short Term/Skilled.

It sounds like these nurses were all thrown to the wolves and didn't know any better. It's really easy to assume if your bosses are asking you to do it - its legal. A big mistake many new SNF nurses make. So sad for everyone.

17 hours ago, KalipsoRed21 said:

My experience with SNFs and/or assisted livings is that the ratio of nurse to patient ratios are often 1:30-40 with some CNAs. So 3-4 nurses may well be all the nursing staff that was at the facility.

If this was a SNF the patient’s are far less stable than those at an assisted living and often have A LOT of care needs. Bed bound, wheelchair bound, peritoneal dialysis, wound care, severe dementia, etc. Assisted Livings are more like what nursing homes were 20-30 years ago, elderly people who need help with medications, minimal assistance dressing, bathing, and meals, etc.

I have no clue why one of these nurses didn’t call 911 within the 3 days. Were these 3 nurses the only ones there all 3 days (It was storm, were other staff coming to work?). Just way to many gaps in the article for me to make a call all the way. Did the nurse reach out to upper management with concerns, was she so overwhelmed and suffering from heath exhaustion his/her self to think through things appropriately? So many questions. But my gut goes the one responsible for these deaths is the person who didn’t make sure the back up generator got repaired/replaced (and/or the person who never approved the budget requests to get it fixed) when they got cited for it during an inspection before this storm took out the electricity.

I agree. Big gaps in the story. I think there is fault well above the nurses level.

Specializes in ED, PACU, CM.
4 hours ago, Wuzzie said:

No, but I’m pretty sure you would not have taken 140 patients in one fell swoop either. We had an ECF with a Norovirus epidemic who tried to send us 40 pooping and puking senior citizens all at once. We refused to take them all and insisted that they divide them between us and the 8 other hospitals in our city. We got 6 which was doable and safe for all involved.

You are correct. We would not have taken all the patients at once. They should have been divided among the local hospitals. The point remains that emergency services were not contacted sooner and people died as a result.