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.
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?
Specializes in Surgical Specialty Clinic - Ambulatory Care.
More than 100 years ago, state and territorial governments established BONs to protect the public's health and welfare by overseeing and ensuring the safe practice of nursing. BONs achieve this mission by outlining the standards for safe nursing care and issuing licenses to practice nursing. Once a license is issued, the board's job continues by monitoring licensees' compliance to jurisdictional laws and taking action against the licenses of those nurses who have exhibited unsafe nursing practice.
Nurse to patient ratios sounds like part of “outlining the standards for safe nursing care” to me.
No not all errors are related to ratios. My point is there isn’t a good way to judge the error as a decisive act of the nurse (impaired judgement, unsafe, un ethical) when the ratios are not already in place. If you are going to work and it feels like Russian roulette as opposed to organized chaos, well then how can ANY error be appropriately analyzed if the situation was unsafe to start? And from judgements I’ve read the BON often judges in a manner that goes something like this, “It is the nurse’s duty to protect the patient and s/he should have recognized the unsafe situation and wrote it down on a piece of paper so we could tell that they knew it was dangerous and so that we know they said something to their manager. “ Giant eye roll here.
It’s like signing up for karate tournament in one on one combat and then suddenly 5 opponents are in front of you. You say something about it and are told that this is what you signed up for by the coaches and then the judges (BON) tell you that you have poor execution of your skills because otherwise you would have beaten all your opponents when you were suppose to only have one.
Specializes in Critical Care, Med-Surg, Psych, Geri, LTC, Tele,.
On 8/30/2019 at 11:04 AM, 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.
The ratios don’t really have a meaningful impact in nursing homes - SNF or ALF. I’m in CA, have worked in these settings. The ratios allow for 1 nurse to up to 35/54 people.
The ratios don’t really have a meaningful impact in nursing homes - SNF or ALF. I’m in CA, have worked in these settings. The ratios allow for 1 nurse to up to 35/54 people.
54???????????????????????????? That's the most ridiculous thing I ever heard..any nurse that accepts that assignment needs a hug.
I was an LVN then. I’m now an RN and work in a hospital...therefore the CA ratios law applies and I only have 5 pts max.
If you worked in the same facility as a RN what will be the pay rate vs when you were a LPN. I would hope you were compensated a lot for all that liability
Specializes in Critical Care, Med-Surg, Psych, Geri, LTC, Tele,.
4 minutes ago, Snatchedwig said:
If you worked in the same facility as a RN what will be the pay rate vs when you were a LPN. I would hope you were compensated a lot for all that liability
Not same facility. As I said as an LVN I worked LTC settings. Now work Acute as an RN- pay is double to triple. Sad state of affairs, ALF/SNF Nurses make less with way more patients than in acute care.
More than 100 years ago, state and territorial governments established BONs to protect the public's health and welfare by overseeing and ensuring the safe practice of nursing. BONs achieve this mission by outlining the standards for safe nursing care and issuing licenses to practice nursing. Once a license is issued, the board's job continues by monitoring licensees' compliance to jurisdictional laws and taking action against the licenses of those nurses who have exhibited unsafe nursing practice.
Nurse to patient ratios sounds like part of “outlining the standards for safe nursing care” to me.
No not all errors are related to ratios. My point is there isn’t a good way to judge the error as a decisive act of the nurse (impaired judgement, unsafe, un ethical) when the ratios are not already in place. If you are going to work and it feels like Russian roulette as opposed to organized chaos, well then how can ANY error be appropriately analyzed if the situation was unsafe to start? And from judgements I’ve read the BON often judges in a manner that goes something like this, “It is the nurse’s duty to protect the patient and s/he should have recognized the unsafe situation and wrote it down on a piece of paper so we could tell that they knew it was dangerous and so that we know they said something to their manager. “ Giant eye roll here.
It’s like signing up for karate tournament in one on one combat and then suddenly 5 opponents are in front of you. You say something about it and are told that this is what you signed up for by the coaches and then the judges (BON) tell you that you have poor execution of your skills because otherwise you would have beaten all your opponents when you were suppose to only have one.
I understand your position but where your idea falls a part is that BONs control nurses and nurses are not the ones in control of staffing.
Your local Department of Health and/or (actually even better), your local Medicaid program or CMS needs to step in and reimburse based upon the nursing ratio.
Nurses are considered a part of the bed fee, the base DRG rate. Facilities are literally incentivized to control labor costs and that is primarily done by controlling nurse to patient ratios.
If CMS included a nurse ratio accelerator or rate augmentation in their DRG reimbursement we would likely see much better staffing.
Everyone complains that hospitals are looking for profit, yes well the government is the one who is providing the incentives to the hospital to reduce nursing headcount. The government is the real devil in this issue.
I can't really say much about the situation but I do have to wonder about the ancillary staff. I worked very briefly as a LVN for a SNF in Southern California. Charge nurse trying to pass meds on 80 patients many of whom were demented. Four CNA's to do vital signs, pass trays do basic bedside care. On my first day I called the director and asked if I could fire people. A stooled patient needed cleaning and I asked his CNA to handle it. She looked at me and said "no". Then she explained that if she did it now he would stool himself again in a couple of hours and she would just have to do it again. It just made sense to her to wait until the end of the shift. I called the director and was told to send her home as off of the schedule until further notice, technically not fired.
Other concerns were finding patients with unstable vital signs that the CNA didn't report to me. Mr. Jones has a fever of 102, Mrs. Smith has a pulse of 140 but it didn't occur to them to tell me.
My heart goes out to SNF nurses, it is a very hard job and makes me really want to die at home in my own bed!
Just remembered having to contact a facility from the ER I was working in. I was transferred to the charge nurse. When I said who I was I got back a Hi Waltie, it's Terry! Can you believe it. I'm the charge nurse! Terry was a work friend who had worked with me as a tech in the ER with CNA training. She had been going for her RN and has just passed her boards the week prior. Oh well, she was a very good ER tech.
Not related the to the above but have had more than a few seizing elders come in to the ER and when we checked the Phenytoin level, it was zero. Yet checking the MAR sent with the patient it was consistently charted by multiple nurses as having been administered.
After I retired I was contacted by the board to see if I would be interested n going to work as a "patient" in SNFs to check on the quality of the care being delivered to the patients. I declined. So maybe a caveat to the staff of some of those facilities. That cranky old codger might just be working for the BRN. Be nice to him.
This whole article reads as a biopic on why nursing homes have strict state oversight. From the never operational generator to the lack of administrative oversight, this seems like a small, mom and pop run facility that has been passed off by regulators because they serve a niche and run on a shoestring budget. The lack of mention regarding owners is downright scary.
KalipsoRed21, BSN, RN
495 Posts
More than 100 years ago, state and territorial governments established BONs to protect the public's health and welfare by overseeing and ensuring the safe practice of nursing. BONs achieve this mission by outlining the standards for safe nursing care and issuing licenses to practice nursing. Once a license is issued, the board's job continues by monitoring licensees' compliance to jurisdictional laws and taking action against the licenses of those nurses who have exhibited unsafe nursing practice.
Nurse to patient ratios sounds like part of “outlining the standards for safe nursing care” to me.
No not all errors are related to ratios. My point is there isn’t a good way to judge the error as a decisive act of the nurse (impaired judgement, unsafe, un ethical) when the ratios are not already in place. If you are going to work and it feels like Russian roulette as opposed to organized chaos, well then how can ANY error be appropriately analyzed if the situation was unsafe to start? And from judgements I’ve read the BON often judges in a manner that goes something like this, “It is the nurse’s duty to protect the patient and s/he should have recognized the unsafe situation and wrote it down on a piece of paper so we could tell that they knew it was dangerous and so that we know they said something to their manager. “ Giant eye roll here.
It’s like signing up for karate tournament in one on one combat and then suddenly 5 opponents are in front of you. You say something about it and are told that this is what you signed up for by the coaches and then the judges (BON) tell you that you have poor execution of your skills because otherwise you would have beaten all your opponents when you were suppose to only have one.