Appendix I: DMR Case Summaries

Summaries of DMR Death Cases Identified as Questionable by the Hartford Courant in Its December 2001 Series on DMR Group Home Deaths

· The Hartford Courant identified as questionable 36 deaths of DMR clients living in group homes. These deaths spanned a ten-year period-three people died in 1991, one in 1992, four in 1993, four in 1994, seven in 1995, two in 1996, five in 1997, two in 1998, three in 1999, and five in 2000.

· The program review committee staff reviewed the mortality review files for each death, as well as any abuse/neglect investigations related to the deaths. From this review, the staff prepared summaries of each case, which are attached.

· Each summary gives some very brief facts about each person -- age, level of mental retardation, number of medications the person was taking at time of death, the number of diagnoses the person had prior to death, and where the person was living at time of death. The person's cause of death is also noted.

· In the remainder of the summary, there is a brief description of the events leading up to the person's death, a tally of what post-death actions were taken, and a description of any outcomes of these actions. The summary concludes with program review staff comments based on its review.

· Individual identifying information such as the client's name or birth date is not included in the summaries in keeping with the confidentiality provisions related to DMR client records, the mortality review process, and the abuse/neglect investigation process.

Glossary of Acronyms/Terms Used in Summaries

A/N= Abuse/Neglect

CAMRIS= the main client database at DMR

DNR = Do Not Resucitate Order

DK = Don't Know

DPH=Department of Public Health

ER=Emergency room

FDA=Food and Drug Administration

HRC=Human Rights Committee

ICU=Intensive Care Unit

IDT=Interdisciplinary Team

OCME=Office of Chief Medical Examiner

OPA=Office of Protection and Advocacy for Persons with Developmental Disabilities

OPS=Overall Plan of Service

Pica= An eating disorder characterized by the repeated eating of non-food substances

PRC=Program Review Committee

RMRC=Regional Mortality Review Committee

STS=Southbury Training School

Demographics

Cause of Death: Acute Thioriodazine Intoxication

Events Leading to Death

· After client came home from work, she told staff she was going to rest in her bedroom and for staff to wake her for dinner

· When staff went to get client, she was found on floor, unresponsive

· Nursing notes say staff ran to call 911 but panicked and did not perform CPR

· Client died from an adverse drug interaction (a new drug given to the client was only on the market for six months and was not contraindicated with the client's current medications)

· Client lived at group home for approximately five years

Post Death Actions

Post Death Actions: Results/Outcomes

· On August 1, 1995, chief medical examiner said death was due in part to new drug apparently interfering with body's metabolism by artificially raising the levels of client's other drugs to potentially toxic levels; advised DMR to take steps to notify all appropriate people

· DMR issued a medical alert on same day as medical examiner's findings to all regional directors, regional health service directors, and licensing staff

· Medical examiner reported incident to FDA as an "adverse drug reaction"

· DMR determined it was not possible for the prescribing physician or other medical personnel to predict the outcome

· DMR issued a Health Bulletin (November 30, 1995) regarding psychotropic drugs and possible interactions

· Death review noted several systemic issues

Program Review Committee Staff Comments

· Regional mortality review was unclear why client's psychotropic meds changed to the new drug and why case manager was not notified timely of psychiatric change

· Temporary approval for psychotropic med change not reviewed by program review committee (PRC). Client's psychiatrist who prescribed med change sat on client's PRC and a representative on the client's human rights committee also sat on PRC and was administratively employed by the provider agency

· State mortality review recommendation to develop an easy-to-use chart re: drug interactions was determined too complex by a DMR consulting psychiatrist and thus never developed

Demographics

Cause of Death: Myocardial Infarction

Events Leading to Death

· Client lived in group home for three years prior to death

· Entered hospital for hip surgery one month before death, diagnosed with moderate cardiac enlargement

· Later admitted to emergency room with leg pain; diagnosed with broken leg; went into cardiac failure during operation; died later that night

Post Death Actions

Post Death Actions: Results/Outcomes

· Regional mortality review committee said client's death was not unexpected, due to cardiac status and that group home provided excellent care and good quality of life

· State mortality review board accepted local findings

Program Review Committee Staff Comments

· Client entered hospital on two separate occasions with a broken hip and a broken leg near the time of death. No abuse/neglect investigation information was in the client's file and the regional and state mortality reviews did not question these incidents, which they could have given the timing of the incidents relative to the client's death.

Demographics

Cause of Death: Multiple Blunt Force Injuries

Events Leading to Death

· Due to inclement weather, provider decided to use public train transportation rather than drive to a planned outing for clients

· Client, said to be "lacking in strong traffic safety skills" and having compulsive behavior, became excited on train platform when a train approached, ran to the platform's edge, and had to be redirected by staff

· Client ran a second time and staff was unable to physically control him and he fell onto the tracks in front of an oncoming train

· 911 was called, CPR administered, and client taken to hospital but died of multiple trauma

· Client lived in group home for 14 months

Post Death Actions

Post Death Actions: Results/Outcomes

· Provider conducted an abuse/neglect investigation - found staff followed safety procedures and did all they could during the situation

· Regional mortality review committee said provider's investigation was monitored by OPA, which stated its satisfaction with results; committee noted client's lack of traffic safety skills was addressed by staff using proven procedures, the incident was unexpected and appropriately dealt with by staff, and that staff are commended for exemplary efforts

· State mortality review board accepted the regional committee's findings

· OPA did not substantiate neglect or make any recommendations

Program Review Committee Staff Comments

· Although the client had compulsive behavior and did not exhibit "strong traffic skills," the regional death review process determined these areas had been addressed through supervision and redirection at the time of the incident, which worked well in the past with this client.

· The death review process also determined the incident was unexpected and dealt with appropriately by staff. The state mortality review process agreed with these findings.

· Committee staff questions, however, whether more staff attention should have been given addressing the client's behaviors after the first incident of him running toward the train tracks and having to be restrained/redirected by staff. Otherwise, provider staff did all it could to help client. A difficult situation.

Demographics

Cause of Death: Multiple Blunt Force Injuries as a Result of Motor Vehicle Accident

Events Leading to Death

· Client was annoyed after a mid-evening confrontation with staff; went to bedroom

· 2 staff were on duty and scheduled until 10 p.m.; 1 staff person left at 9:20 p.m.

· 2 off-duty staff came to the house for a brief period from 9:40-9:45 p.m. (one claimed to have seen what he thought was the client in his bedroom during that time)

· Client left the house and was spoken to twice by town resident at a public place at approximately 9:45 p.m.; the town resident called 9-1-1 - the DMR investigation determined the client left the residence no later than 9:10 p.m.

· Alarm system in the house was not activated

· Client stole and then crashed a car and was fatally injured

· Client lived at group home for 2 ½ years

Post Death Actions

Post Death Actions: Results/Outcomes

· Regional and state mortality reviews called death an accident

· DMR investigation substantiated provider neglect; made multiple recommendations, including obtaining criminal histories before hiring direct care staff

· OPA both agreed and disagreed with several of the DMR investigation findings regarding substantiated neglect or abuse. OPA also made several protective service/systemic recs.

· Staff now go through criminal background checks

· Provider eventually lost contract for this home and all other homes in this region

· Lawsuit settled for "several hundred thousand dollars"

Program Review Committee Staff Comments

· Staff not aware client was missing for at least six hours, including after a formal shift change less than an hour after investigation determined client left house

· Provider did not get formal DMR approval prior to installing alarm, nor was there a record of formal staff training or written operations relating to the system, including regions of the house routinely bypassed by staff

· A rebuttal to the investigation report from the provider noted all provider staff were trained in using the alarm system; also noted the department's licensing inspectors never cited the provider due to a lack of training on the alarm system despite regular DMR inspections

· Why did DMR permit an asleep 3^rd shift staff given clients' "need for supervision" based on their documented behaviors

· DMR investigation found provider's personnel practices deficient in staff screening, hiring, evaluation, and discipline (disputed by the provider rebuttal) - unclear what department's oversight role is in these areas

Demographics

Cause of Death: Asphyxia, Secondary to Foreign Body in Throat

Events Leading to Death

· After 26 years at Southbury, the client moved to a one-person private group home specifically designed for his needs, with the expectation at least one other client would later move in

· Less than one month later, the client died as a result of a choking incident -he grabbed food allegedly in sizes exceeding the client's food guidelines, ran away from staff, and choked

· Staff called 911 and tried to intervene doing Heimlich Maneuver and CPR before emergency help arrived; ambulance took client to hospital where he died

· Client had a 1:1 supervision requirement, meaning he was to be within an arm's reach of a direct care staff person at all times while the client was awake

Post Death Actions

Post Death Actions: Results/Outcomes

· A lawsuit filed by the client's family is pending and the provider has submitted a written rebuttal to the DMR investigation report

· A DMR investigation was conducted and cited neglect on part of provider management for not ensuring staff were adequately inserviced on client's food prep guidelines (currently disputed by provider)

· Regional and state mortality reviews were conducted - both accepted the DMR investigation findings and recommendations

· The provider has so far agreed to inservice all appropriate staff on any specific food prep guidelines for clients, and will record attendants' signatures, titles, and training dates - as recommended in the DMR investigation report; any other personnel or programmatic actions are pending the result of the lawsuit

· OPA agreed with the DMR investigation findings of substantiated neglect and made a recommendation for DMR to ensure upon the transition of any client with specific food guidelines that formally documented procedures be in place and that such guidelines are given to the new provider prior to the transition process.

Program Review Committee Staff Comments

· The DMR investigation cites 12 different documents available to the provider where the client's behaviors (re: grabbing food/running) and food guidelines were noted in information between STS and provider - the provider is disputing the investigation results

· Although the same DMR client transition processes used in moving Mansfield residents are to be used for Southbury residents, including the transition of this client, it is unclear whether the new provider was fully aware of client's food guidelines as part of the transition process.

· The regional mortality review committee gives conflicting answers as to whether care before the client's death was appropriate; the regional review process was also held three weeks before DMR's investigation report was completed, which DMR reports is not unusual. The department says the death review process should be delayed by a pending investigation.

· DMR is continuing to work on developing standardized nutritional guidelines, as recommended by the state mortality review board.

Demographics

Cause of Death: Cardiopulmonary Arrest, Secondary to Pneumothorax

Events Leading to Death

· Client was taken to emergency room with gastric problems (had history of increasing gastric ailments)

· Surgery was performed; client said to be uncooperative in terms of pulling out IV lines, including antibiotics

· Provider hired private "home health agency" to monitor client while in hospital (i.e., making sure IV lines are not removed) - later determined by the state mortality review board, through DPH, the agency was not licensed by DPH as home health care agency

· Client pulled out IV lines apparently and missed antibiotics over the course of approximately 12 hours, developed high fever day before death; two hours before death IV line removed; central line put in, client's health deteriorated, CPR performed, but client died of cardiac arrest and pneumothorax

Post Death Actions

Post Death Actions: Results/Outcomes

· Regional mortality review committee said client safety while in hospital could have been better protected by hospital; hospital has historically had health care problems; DPH investigation warranted, but pneumothorax probably could not have been prevented

· DPH investigation confirmed several deficiencies on part of hospital - allegation that patient did not receive IV fluids/antibiotics for 12 hours was partially substantiated

· Hospital submitted plan of correction to DPH

· State mortality review board accepted regional committee's findings/recommendations, and inquired from DPH whether private monitoring agency was licensed as home health care agency.

· OPA agreed with DPH investigation findings of "partial substantiation" of hospital neglect in that client did not receive the appropriate intervals of antibiotics.

Program Review Committee Staff Comments

· Private hospital monitoring agency must be required by MD order, but no such order in file or found during DPH investigation

· Unclear why client's removal of IV line was not acknowledged by hospital for an extended period of time

· Surgical procedure performed without first receiving guardian consent

· Although it is a hospital's responsibility to define the role of a "monitoring agency," unclear why DMR did not send out any guidelines re: private monitoring services specifically after agency called itself a home health care agency although not licensed as such by DPH

· Hospital did not seem to fully know DMR procedures re: guardian consent

Demographics

Cause of Death: Suicide by hanging

Events Leading to Death:

· Client had been living in the home for 12 years

· During evening prior to death -- client had pizza with housemates and staff, and talked on the phone to family and friend.

· Not seen by staff preparing for bed or in bed.

· Client found about 6:00 am fully dressed, hanging from closet rod by bathrobe belt. The staff person on overnight shift indicated he had "checked" on client several times by listening at the bedroom door.

· The staff person had worked regular shift - 2 p.m. Thursday to Friday 6 a.m., then part of the 1^st shift on Friday morning (because someone called in absent) then came back for 2 p.m. shift on Friday until Saturday a.m.

Post Death Actions

Post Death Actions: Results/Outcomes

· No charges filed as a result of the local police investigation.

· The A/N investigation was conducted by the private provider. It did not substantiate neglect.

· Office of Protection and Advocacy monitored provider and local police investigations, and mortality reviews. OPA asked for further information -- bed check policy, legible staff log on night of incident, and when client was last bathed -- and made 3 recommendations, including implementation of mortality review findings.

· Regional Mortality Review made 7 findings or issue areas including: - the autopsy did not indicate a time of death, and - policy on staff hours allowed to be worked and made three recommendations: 1) in-service staff on warning signs of depression and/or suicidal intent; 2) better documentation on clients' daily activities; and 3) close case.

· State Mortality Review also question the number of hours staff can work per day; the fact that post mortem does not cite a time of death, although the police report indicates a conversation with Medical Examiner indicating it was soon after dinner, no one able to determine why staff gave conflicting information.

· Same recommendations as RMRC plus check with OPA on status of A/N report; check on status of staff person involved; and staff training on better record keeping (Region to follow up).

Program Review Committee Staff Comments

· Private provider "investigation" consisted of interviewing 2 staff persons.

· The agency investigation does not appear to have considered the autopsy report, the police report, nor does it appear the staff was questioned on the staff log w/scratched-out entry indicating client was fine in the am, (several hours after the death occurred) nor questioned as to whether he had fallen asleep.

· Discussion w/provider indicates they have not changed staff work policy - always had a prohibition against working more than a straight double shift; and had instituted a policy on overnight check-ins by staff that was in place at the time of client's death. This type of scheduling could still happen and yet comply with policy of no more than a straight double.

· No disciplinary action was taken against staff.

Demographics

Cause of Death: Foreign body in larynx

Events Leading to Death

· Client had lived in home for 10 months

· Client choked at dinner while staff was serving other clients their plates

· Staff performed Heimlich - no response; Called 9-1-1. Conflicting information about whether staff started CPR. EMTs arrived with tool - removed piece of food, transported to hospital ER. Could not be revived.

Post Death Actions

Post Death Actions: Results/Outcomes

· RMRC conducted initial review - found that there were no eating guidelines in place for the client, even though family indicated food needed to be cut up.

· RMRC recommended reopening case once DMR investigation completed. DMR issued report 18 months after death. Findings substantiated program neglect - no plan for cutting food size open to staff interpretation-and even though staff running notes indicate food stealing behavior, no plan for this; failure to report incidents; found neglect on part of staff nurse and falsifying records on part of house manager.

· Investigation makes 8 recommendations -- provider review findings to see if personnel actions are warranted; better training on responsibilities, better training of CPR; better intake process; referral of neglect findings to regional community training home coordinator (2 staff also provide services) there. Regional contract managers to follow-up.

· Regional Committee at 2^nd review - after DMR investigation completed - found that the medical and personal care was not timely or appropriate, and supported the recommendations of the investigation.

· State Mortality Review agreed with local findings (essentially the investigation findings) and recommended regional follow-up with provider to ensure recommendations implemented.

Program Review Committee Staff Comments

· Provider had been cited in previous licensing inspection (a year before client death) that documentation was lacking to show the process for updating staff on client-specific info (like eating guidelines).

· Apparently the correction plan from provider was filed. Client had been in home less than one year - client specific information very important until staff becomes familiar with client.

· Psychiatric evaluation does not mention food-stealing behaviors, not clear if rest of IDT knew about these behaviors.

· Does not appear medical examiner was contacted to do autopsy as should be done for sudden, unexpected death. Police not called.

· Staffing in home was minimal at time of incident - one staff for 6 clients - but not clear whether the staffing patterns were looked at to see if this was the usual staffing ratio, and if so, whether adequate given need for eating monitoring.

· Not clear from file documentation if and how the recommendations were implemented. Took 4 months after death for A/N report to be filed. Not clear if OPA agreed with DMR investigation findings.

Demographics

Cause of death: Cardiopulmonary arrest

Events Leading to Death

· Client lived at home but was in DMR respite care for a few days. Client had been this respite before.

· Client had a seizure disorder and was on medications Client had some medications at the respite from previous stay.

· Mother sent additional meds. Staff added the newly sent meds from envelopes to the bottles of meds on-hand, without counting.

· About 5:30 am client found unresponsive in bed. Client had discharge from mouth.

· CPR started 9-1-1 called. EMTs and State police responded. Client pronounced dead by EMTs at the respite.

Post Death Actions

*DMR settled- Paid $875,000

Post Death Actions: Results/Outcomes

· Almost immediately after client's death father claims that client not given all medications at the appropriate times during stay at respite. State police took all remaining medications with them for their investigation.

· No criminal charges filed by State police. DMR investigation delayed 2 months until State Police ok'd to proceed.

· Regional mortality review could not adequately interpret autopsy results because apparently not enough blood was taken to adequately screen for client's med levels; RMRC also found other problems with autopsy report.

· DMR investigated for A/N. Did not substantiate. OPA disagreed and found neglect.

· Even though neglect was not found by DMR, nursing staff was "counseled" on accepting medications

Program Review Committee Staff Comments

· Autopsy was conducted by a pathologist at the UConn Health Center, not OCME. It is unclear whether DMR contacted the Office of Chief Medical Examiner about conducting the autopsy.

· DMR staff contacted a local medical examiner who did not accept jurisdiction. He did not come to the scene, but based on DMR staff description and client's medical history, ruled the death natural.

· On the day of the death, the State Police contacted the OCME and was told that, based on information from local ME, there would be no autopsy.

· Program review could find no documentation as to which DMR staff had called the ME, and what information had been conveyed. Further the state police report does not indicate that the OCME was informed of the medication issue when SP made contact, thus there is no clear indication that the OCME knew about the medication an issue when autopsy decision was made.

· Both DMR staff and state police knew very soon after client's death that med. administration was an issue, since the client's father was very agitated/upset about the medicines at the respite center, and the state police had seized the medicine bottles as evidence.

· Nothing in documentation indicates what the pathologist at UCHC was told regarding the medication issue and why not enough blood was taken for adequate medication screenings. Autopsy was reviewed by OCME for state police; determined no criminal aspects to the death.

· OPA found problems with autopsy including wrong dates, no clear time or cause of death.

· State Police report apparently not reviewed as part of the Mortality Review process, was not in file and DMR initially stated that a SP investigation had not been done. Program review pursued getting the state police investigation report through the Director of Investigations.

· Even though DMR did not find neglect, the region developed a Quality Improvement Plan for the respite Center making specific people responsible for particular tasks for correction/improvement. One LPN eventually terminated for continuing med errors.

· Program review found client profile sheet used by respite center not thorough, that one of client's medical diagnosis (asthma) was not on the sheet, and food consistency guidelines were contradictory.

Demographics

Cause of death: 1) Respiratory failure; 2) Recurrent aspiration pneumonia

Events Leading to Death

· Client had lived in this CLA for almost 2 years

· Over 6-month period prior to death, client had recurrent aspiration pneumonia.

· Increasing episodes of gastrointestinal problems - reflux, abdominal distention, and vomiting. Hospitalized for a diverting colostomy. Surgery performed; ok for 48 hours.

· Then found unresponsive on 3^rd day post-surgery. Full ACLS initiated; transferred to ICU. DNR put in place -died following day.

Post Death Actions

Post Death Actions: Results/Outcomes

· Regional mortality review found care appropriate and timely. Stated he was a medically involved client; cause of cardiac arrest in hospital could not be determined.

· DNR properly documented.

· OCME did not accept jurisdiction -- no autopsy. No hospital autopsy. RMRC recommended to close case.

· State mortality review examined case (even though not referred by region) agreed with regional findings.

Program Review Committee Staff Comments

· RMRC indicates DNR properly documented. DNR was not in file.

Demographics

Cause of Death: Subdural hematoma due to fall

Events Leading to Death

· Client had lived in this home for more than three years

· Client had Down Syndrome with Alzheimer's

· Had a series of incident reports related to falling and increasing behavior issues including disrobing and slapping staff.

· Had a choking incident a year prior to death - had dysphasia evaluation - with recommendation to chop food smaller, use smaller spoon, and limit size of bites.

· Also had a geriatric assessment and several other evaluations - found declining cognitive skills. By days prior to death, could no longer feed himself or perform ADLs.

· Client not well - RN called -- RN advised take client to ER. Admitted to hospital, CT scan showed bilateral chronic subdural hematoma.

· Hospital Intensive Care Unit full; taken to regular floor.

· Surgery performed to relieve bleeding. Did not regain consciousness; CT scan showed large re-bleed.

· Niece/guardian opted for no 2^nd surgery.

Post Death Actions

Post Death Actions: Results/Outcomes

· RMRC states there was no allegation of neglect or abuse, but "caregivers did not provide a safe environment to protect him from harm"

· RMRC recommends team be convened to review issues in the case

· MQAB states injury of unknown origin; makes A/N allegation on 3/28/02; investigation report pending (10/02)

Program Review Committee Staff Comments

· Provider had taken client for several assessments and evaluations related to his deteriorating cognitive skills and increasing behavioral incidents

· Case Management notes indicate client had cut back on day program - had fallen off chair at Day Program and taken to ER

· IDT continues to "voice concerns" about his sleeplessness at night and increasing falls; Case Manager to look at alternative placements;

· No documentation that IDT requests safety belt approval for chair use to prevent falls

· Program review questions whether this is a case of neglect or one where the client was no longer appropriately placed and IDT did not find another placement. Provider had sought assessments/evaluations for client) and shared results w/ IDT.

· A/N allegation comes up almost two years after death

· Not clear if regional team was ever convened or what it found/recommended

Demographics

Cause of Death: 1) Respiratory arrest; 2) Aspiration; 3) Seizure disorder

Events Leading to Death

· Client had lived CLA about 2 years

· About one month before death, client put on new medication to control seizures

· Experienced grand mal seizure 3 weeks before death - had respiratory difficulty

· Had another seizure shortly after and went into cardiac arrest

· 9-1-1 called; taken to ER by EMTs

· Put on ventilator and resuscitated -- admitted to ICU

· Deteriorated over ensuing 2 weeks

· About a week before death - tracheotomy and g-tube put in place and client remained on ventilator

· Diagnosis of systemic inflammatory response syndrome (multi-system failure)

· DNR put in place after following DMR protocols; life support withdrawn; died hours later

Post Death Actions

Post Death Actions: Results/Outcomes

· RMRC found medical and personal care appropriate, hospital calling on medical specialists to determine cause of deterioration

· Found CLA staff acted appropriately getting client to ER

· Recommends a report of possible drug interaction (with multi-system failure) to FDA. Region to check on clients in that region to assess others on that drug

· State mortality review agreed with local findings - reported to FDA

Program Review Committee Staff Comments

· A/N allegation concerning this client at the CLA after the client went to hospital (not related to death); not substantiated, determined to be related to union and strike issues.

· Another abuse allegation 2 months before death was substantiated

· LPR&IC staff not sure if clients in the region were ever assessed for that particular drug use; or if clients in other regions were assessed

· No FDA response -- DMR FDA does not respond to every report of a possible drug interaction, would send out an advisory if there was concern about the drug

Demographics

Cause of Death: asphyxia due to drowning (bathtub)

Events Leading to Death

· Client in private CLA geared to mentally retarded children, had lived there 7 years

· Late afternoon -- Group of nursing school graduates touring home at the time

· 2 staff started to bathe client; placed client in tub ¾ full of water

· Staff had used bathing chair for client had but did not strap client in

· 1st staff person left bathroom w/dirty laundry and stayed in family room w/other clients

· 2^nd staff person left bathroom to get client's meds (no meds found in bathroom later)

· 2^nd staff returns to bathroom -- finds client submersed in tub -- lips blue, not breathing

· 9-1-1 called; EMTs and local police department responded

· Transported to hospital ER. Pronounced dead.

Post Death Actions

Post Death Actions: Results/Outcomes

· Criminal charges of manslaughter in 2^nd degree and risk of injury to minor filed against one staff person. Staff person pleaded guilty to the risk of injury charge. Judge sentenced staff to a 5-year suspended sentence and 5 years of probation, and imposed stipulation that staff not work in health care or childcare in future.

· DCF conducts A/N investigation -- found neglect on part of one staff person (not the 2^nd)

· Investigation listed a number of programmatic concerns -- not unusual for staff to leave a client alone in tub to get towels, clothing, or meds; also not unusual for staff to not use straps on the bath chair

· Investigation found no formal training or competency test on use of bath chair to ensure staff know how to use

· Quarterly reviews of the last OPS had not been shared with staff (over 2 months)

· Regional Mortality Review and State Mortality Review stated they had no medical records to review (taken by police and DCF for investigation) so findings or recommendations were limited to the social summary and case management notes

· DMR management staff conducted its own "root cause analysis"

· Private provider subject to intense monitoring by case manager and contract monitors - at least 8 visits in 6 weeks after death

· Bathing procedures are now required to be in place for each client in CLAs and checked at site visits

Program Review Committee Staff Comments

· Program review staff found the DCF investigation very thorough, but was unable to determine why in one version of the DCF report there were two finding areas that were crossed out and in a version of the report issued two days later those findings were not included

· Licensing and Inspection had cited the home in previous year for not having clear updates in the OPS on use of safety equipment; provider filed a correction plan. Provider indicated to program review that deficiencies addressed - doctors' orders for bathing straps in place and implementation of safety protocols for bathing, eating, ambulating and transportation for all clients.

· No indication that regional or state mortality review considered either the local police report or the DCF investigation in reaching findings about care in the case. State mortality review states just that they did not have medical records to evaluate, and that local PD in charge of the case.

· The private provider submitted its response to the investigation, which included actions the provider planned to take but also discussed where provider took exception or found issue with findings

· Case points to a miscommunication (or misinterpretation) of what actually happened to client when 9-1-1 was called and brought to ER. Only at ER did it become clear that child went underwater in bathtub - EMTs thought he had seizure. 9-1-1 tape not part of the document so not clear what CLA staff told the dispatch.

Demographics

Cause of Death: Aspiration pneumonia

Events Leading to Death

· Client had lived at regional center for about 20 years

· Client had bouts of respiratory infections and recurring incidents of aspiration pneumonia

· Had a feeding tube inserted year prior to death; client continued to aspire on regurgitated material.

· Client also had chronic urinary tract infections

· Had several hospitalizations- client returned back to regional center; continued antibiotics and suctioning

· Client was changed and turned about 3:30 am. - staff discovered client unresponsive at 4:05

Post Death Actions

Post Death Actions: Results/Outcomes

· Autopsy conducted by OCME -- showed therapeutic levels of anticonvulsant drugs

· Autopsy also found cause of death chronic aspiration with early bronchial pneumonia; found previously undiagnosed hydrocephalus but not progressive and not cause of death

· Regional and state mortality reviews found medical care appropriate - involvement with family well-documented and family wishes appropriately considered -- no recommendations

Program Review Committee Staff Comments

· Parents had initially not wanted the g-tube inserted (their belief was that they did not want to prolong client's suffering) eventually agreed.

· Not sure why autopsy was done by OCME in this case, while jurisdiction not taken in earlier case with very similar circumstances

Demographics

Cause of death: Asphyxia due to aspiration of food bolus (choked on food)

Events Leading to Death

· Client had lived at the Regional center for 14 years

· Client had line-of-sight requirements; when in community 6 feet line-of sight

· Client had history of stealing food and gorging (client at one time had a diagnosis of PICA)

· Client had recent incidents of bolting and stealing food

· Client was on way to day program. At parking lot where clients transferred from DMR van to the day program van, staff were outside the van and client was able to access lunchbox

· Client choked on sandwich. 9-1-1 called. Heimlich maneuver and CPR performed. Transported to hospital by ambulance. Pronounced dead.

Post Death Actions

*Case settled. Private provider paid an undisclosed amount

Post Death Actions: Results/Outcomes

· Police investigation -very brief police report, no criminal charges filed

· DMR conducted A/N investigation-neglect substantiated, and other programmatic concerns were substantiated.

· 9 separate findings including: no clear guidelines about supervision needed by client on van - staff left to interpret

· Staff unaware that client needed food chopped to a certain size

· DMR unable to provide in-service (training) records for the 4 people present during the incident. Day program provided training documentation for its staff

· Client had PICA behaviors but no behavior plan in place - no documentation of PICA no longer an issue

· Other clients at client's residence also showed PICA and/or food-stealing behavior; not addressed as target behaviors

· Other clients on van had these behaviors, yet investigators found many items in both vans (e.g. in DMR van - hard candy, fish hook, cigarette butt; in private sandwich bag with orange powder from crackers client ate before choking)

· Private provider staff did not use cell phone in van to call 9-1-1 told other people to call. EMTs took "too long" according to staff on scene

· 11 recommendations made by DMR investigators. Regional mortality review states recommendations need to be implemented and residential documentation needs to be more specific and address target behaviors and incidents

· State mortality review sends a memorandum to Regional Directors and Southbury Training school to review procedures for keeping vans cleaned and other safety issues around vans (maintenance and safety belts)

Program Review Committee Staff Comments

· DMR investigation very thorough.

· Don't know if recommendations were implemented -- investigation report does not make specific person responsible for follow-up or implementation (mostly DMR central region responsible)

· Don't know if any personnel actions were taken, those are not part of the investigation report

· The PICA behaviors not addressed in the plan yet no documentation of being discontinued is similar to the circumstances in one of the other cases in this case review (other case happened about 3 years earlier)

Demographics

Cause of Death: Aspiration of foreign body (choked on a tiny rubber ball)

Events Leading to Death

· Client lived in a CLA with 4 other people

· Client did have an eating program - cut all food into small pieces to avoid choking only small amount to drink and remind him to drink slowly. Staff must be seated at table with client

· A relative of one of the other residents brought the young woman an Easter basket

· Apparently the client took the small rubber ball (which was attached to a paddle) from the Easter basket, thinking the ball was a candy

· He began choking - staff did not know what he had eaten. According to police report, staff thought it was a marshmallow

· Staff attempted the Heimlich maneuver 9-1-1 was called - Police and EMTs (from fire dept.) responded. He was still breathing when they arrived. Police apparently instructed staff to sit client down and let client relax to get the choking material down

· Client stood up, turned blue, then collapsed. EMTs and police checked client -- no breathing, no pulse.

· CPR started -- transported to hospital ER-client could not be revived

Post Death Actions

Post Death Actions: Results/Outcomes

· There was a police report - no criminal charges filed

· Private provider interviews 3 staff people on duty at the time -- but no investigation was conducted

· Regional mortality review indicates services and care appropriate and that cause of death was not anticipated nor preventable - stated client had no history of PICA.

· Regional mortality review commends staff for excellent care provided to client and for the attempts to provide emergency treatment before client died.

· State mortality review agrees with local findings and made no further recommendations

Program Review Committee Staff Comments

· Program review staff questions why there was no neglect investigation - many questions remain unanswered when no investigation is conducted.

· No documentation in file that client required line-of-sight supervision, but client did have an eating program because there was a concern about choking.

· Regional concern should not have been about PICA -- client had no history of PICA - but about having access to food that was larger than client could eat. (i.e., client may have swallowed rubber ball believing it was edible)

· Issue raised in the Hartford Courant article about the provider's payment of the client's life insurance policy to the family with the provision that family not file a lawsuit and whether that was appropriate.

Demographics

Cause of death: Asphyxia due to neck compression (Client was caught between bedrail and mattress)

Events Leading to Death:

· Client had been in group home for 8 years

· Client had hospital bed with rails; client also needed to be repositioned every two hours.

· According to staff log, client was checked at 1 a.m., 2:30 a.m., and 4:15 a.m.

· Client was found by day shift staff at 7:10 a.m.-client was wedged between bed siderail and mattress with his neck on the bar that attaches the rail to the bed

· Client was not breathing and was cold to touch

· Police and medical examiner called - both responded -- medical examiner came to scene and pronounced the client dead

Post Death Actions

Post Death Actions: Results/Outcomes

· Local police investigated - no criminal charges filed

· A/N investigation conducted by DMR - neglect substantiated

Investigation found:

· There was no provider documentation requiring bed checks;

· Required repositioning required every 2 hours was not done (apparently staff thought other staff had done it);

· LPN recorded repositioning done when it was not

· CPR not started by any of the 5 staff who were there at the time client found -- all thought he had been dead too long

· Staff called Asst. Residential Coordinator before calling 9-1-1

Program Review Committee Staff Comments

· When staff called 9-1-1 told by police not to touch body - don't know if that is why CPR not started

· Provider emergency procedure does not clearly state when to start CPR, nor does DMR policy

· New beds had been delivered in previous few months, but provider did not contract for new side rails

· Provider used the old rails from the old beds, installed by provider

· Case manager indicates there were no issues raised at IDT about client safety and bed rails

· The Food and Drug Administration had issued a bed rail advisory in 1995 (3 years before client's death); it went to DMR but the agency did not distribute it nor alert private agencies

· DMR issued its own bed rail advisory in 1998 (after client death) that went to all regions and providers. Advisory revised in 2000 to address water and air mattress issues.

· Committee staff is not clear what, if any, disciplinary actions were taken against personnel involved.

Demographics

Cause of death: Acute pulmonary edema due to aspiration of gastric content and small bowel obstruction (Client swallowed a rubber glove)

Events Leading to Death

· Client was living in a DMR home; had been there 4 years

· When client was placed there it was noted that client had serious PICA behaviors and there was behavioral plan in place for that.

· Staff found client at 4:45 a.m. Client twitching on bathroom floor.

· Staff called "unit" nurse who said to call 9-1-1. 9-1-1 called.

· Taken to hospital. Client admitted to hospital with dehydration and Tegretol (one of client's meds) toxicity.

· Died a day later

Post Death Actions

Post Death Actions: Results/Outcomes

· Autopsy found client had ingested 2 rubber gloves and other inedible items - clothing tags

· DMR conducted A/N investigation; neglect substantiated

· Investigation found: Client's PICA condition was not monitored adequately - significant incidents of PICA had occurred and IDT failed to address

· Week before death the day program had written an incident report of PICA

· Regional Mortality Review found that residential unit did not monitor client's PICA adequately and did not utilize appropriate safeguards in storage and disposal of inedible items.

· RMR found communication between hospital and DMR staff was inadequate

· State mortality review agreed with regional findings; also sent letter to DPH requesting an inquiry into lack of surgical consult while client in hospital.

· DPH conducted inquiry into doctor's failure to get a surgical consult -- inquiry found no reason for action

· Disciplinary action recommended for group home staff and IDT members who knew (or should have known) about PICA and did not take action

Program Review Committee Staff Comments

· OCME declined jurisdiction -- DMR pursued local hospital pathology dept. to conduct autopsy;

· Not clear what the group home staff told the hospital staff about the client's PICA condition; May have been only late in the evening (after early morning hospital admission) and upon questioning about client's abdominal scar that staff conveyed information about previous surgery related to PICA; conflicting statements

· Region issued a rubber glove advisory - cautions people about disposal of rubber gloves and other inedibles-- went out to all regions/providers

· A more comprehensive PICA advisory was sent out to South Central region only; only after OPA questions why the guidance wasn't sent to all regions/providers is that corrected;

· Probably should have been a reminder about incident reporting. The incident of PICA week before client's death not reported on CAMRIS; not clear if Day Program wrote the incident to residential program and they did not report

Demographics

Cause of Death: Cardiac arrest after aspiration

Events Leading to Death

· Hospitalized with pneumonia about 2 weeks before death

· Returned to group home with antibiotic

· A few days before death nursing notes indicate client increasing sleepy; poor facial muscle tone; can't keep eyes open or support head;

· Two days before death client being fed; choked on milk and began to wheeze

· Staff performed Heimlich and CPR; 9-1-1 called; transported to ER

· Revived and put on ventilator; admitted to ICU

· Dopamine started but client essentially brain-dead;

· Discussion between family and MD; Dopamine discontinued but remained on ventilator;

· Died a few hours later

Post Death Actions

Post Death Actions: Results/Outcomes

· Regional Mortality Review indicates that because of Alzheimer's and choking, probably should have had an occupational therapist with a special focus on eating (swallowing problems) evaluate client.

· Noted that a habilitation specialist was following client re: mealtime procedures

· State mortality review agreed with local findings

Program Review Committee Staff Comments

· Client's deterioration was noted

· Had a medical consult with a pulmonologist about 18 months prior to death and notes airway disease and recurrent pneumonia but does not recommend a swallowing evaluation

· Had a psychiatric consult a few months before death - about sleeplessness-Melatonin for a while but no help

· Committee staff noted client had eating guidelines in record but they did not indicate who developed them or when developed, and made house manager responsible for implementing them

· About a month before death Day Program indicates client is deteriorating - uncoordinated, agitated; confused, hallucinating and can't eat or drink by himself; but does not appear client's IDT met to address this rapid decline and whether placement remained appropriate

· Committee staff could not locate information on this client in the department's CAMRIS system

Demographics

Cause of Death: 2^nd and 3^rd degree burns due to scalding bath water

Events Leading to Death:

· Client had been in the home 9 years

· At the time the home had 13 residents and 2 staff people were on duty

· Clients were quite high-functioning; this client always ran and took her own bath

· The client always took her bath downstairs; this particular day the client ran her bath upstairs

· Another resident went upstairs and called down that client was yelling from the bathroom

· Staff found her in the tub - water still running - client was vocal and breathing

· Staff called for help from others in house; lifted client out of the tub

· 9-1-1 called; Police arrived and instructed staff to apply cold wet towels.

· EMTs arrived and applied gel sheets; transported to local hospital

· After assessment at local hospital, transferred to downstate Hospital burn unit

· Developed hypertension and cardiac status failed

· DNR put in place by sister/guardian; died one day later

Post Death Actions

Post Death Actions: Results/Outcomes

· Regional Mortality Review determined the incident "an unfortunate accident"

· Regional mortality review concludes when a licensing waiver is issued should be reviewed annually

· State mortality review agrees with local findings

· Also finds that DMR and group home were not aware of the DNR put in place by sister

· State mortality review sent letter to inform doctor in case of DMR's policy relative to DNR orders

· Regional DMR staff conducted investigation

· The investigation found no neglect

Program Review Committee Staff Comments

· The police came to the scene but apparently there was no police investigation

· No mention was made in any of the investigation results or mortality review results that the house had 13 residents and 2 staff on duty. This was the staffing pattern in the home's licensing file at that time with DMR

· Since 1992, the number of residents in this home has gradually decreased (home now licensed for six). Discussion with DMR indicates there was a plan in place to reduce the number of clients in the home even before death,

· From committee staff's review of the licensing file, it is unclear if all of the residential number reductions were prompted by DMR or by the private provider (at least some of the most recent reductions were required by DMR)

· The licensing waiver - on hot water temp - was first allowed in 1986 by then Director of Quality Assurance

· Reapplied and granted the waiver in 1990 - no date given for expiration. Licensing inspection (6 months before death) cited for temp of 150 (should be 120). No action taken because of waiver.

· State mortality review appears more focused on DNR and not being notified - than cause of the death and prevention

· Some time after death the home was investigated - because of other allegations including sexual activity-and put on more intensive monitoring

· Quality Assurance sent out information on hot water and burn dangers

Demographics

Cause of Death: Respiratory failure due to adult respiratory distress syndrome

Events Leading to Death

· Client had lived in home for 2 years

· Client had many health problems including cerebral palsy, had had 2 spinal fusions; respiratory problems, spastic bladder; and intermittent pressure sores;

· Requires total nursing care;

· Client had developed headcold symptoms; treated at home

· Sent to ER - temp 101.6

· Client intubated and improved temporarily, but developed septic shock

· DNR order put in place day before he died

· Family did not wish autopsy

Post Death Actions

Post Death Actions: Results/Outcomes

· Regional Mortality Review had no findings but due to high profile of this DMR home - several other deaths occurred there - it was referred to State Mortality Review

· State Mortality Review agreed with local findings

Program Review Committee Staff Comments

· Had been an allegation of physical abuse - related to giving client a cold shower and spraying water in client's face several months prior to death. Had been a "special concern" but was raised to level of investigation when staff called Office of Protection and Advocacy. Not clear whether DMR intended to handle this internally before OPA was called.

· The allegation of abuse was not substantiated by DMR

· OPA disagreed with DMR's finding, did its own investigation and stated neglect substantiated

· The staff who made the allegation was later terminated (not clear why).

· The same former staff person, through attorney, made a neglect charge after the client died. It was related to the same cold shower incident, but the charge also stated the incident had contributed to the client's death. Allegation was investigated by DMR and OPA separately, and not substantiated.

· Neither the regional or state mortality review file documentation mention either A/N allegations or findings. Neither considered, even though both would have been available during the review.

· DMR staff probably should have been reminded how any allegation of neglect/abuse needs to be reported immediately

Demographics

Cause of Death: 1) Septicemia; 2) Small bowel obstruction

Events Leading to Death

· Client lived in this home about 10 months

· Client very medically involved - had a g-tube-and required round the clock nursing services

· Client also had direct and consultative physical therapy services

· Had several prior hospitalizations prior to death, mostly for pneumonia

· Hospitalized for 8 days 1 month prior to death with gram negative pneumonia

· Discharged from hospital - condition had improved - but prognosis guarded

· Developed diarrhea with increasing fever

· Admitted to hospital with hyperthermia; had x-rays of abdomen and surgical consult

· Had exploratory laprascopic surgery and found bowel obstruction; surgery to remove

· 1st surgery -- abdomen still distended, no bowel sounds --not successful, given morphine for pain

· 2^nd surgery-placed on ventilator-condition continued to deteriorate for 4 days

· Doctor speaks w/family and client taken off ventilator

· Client dies hours later

Post Death Actions

Post Death Actions: Results/Outcomes

· Regional mortality found overall health care to be excellent

· Communication with guardian a concern - group home did not have an accurate phone number

· Guardian not aware of hospitalization until 2 days after admitted

· Found hospital care to be aggressive and appropriate to DMR

· Regional directive sent to DMR homes to remind staff of responsibilities in calling family/guardian in medical situations

Program Review Committee Staff Comments

· Does not appear there was a DNR in place, even though client taken off ventilator with comfort measures only

· Does not seem to be addressed by either mortality review

· Not sure if notice was sent to private homes as well on the responsibility to call family and guardians

Demographics

Cause of Death: Sepsis; Pneumonia; and Chronic Obstructive Pulmonary Disease

Events Leading to Death

· Client had lived at this home for two years

· Client was very medically involved - had many hospitalizations in two years prior to death for aspiration pneumonia

· Had been on life supports with prior hospitalizations

· At 9:30 a.m. LPN notes facial edema (swelling) and wheezing

· Staff called doctor; said notify if respiratory distress increases

· By evening, doctor called again-doctor told staff to bring to hospital

· Ambulance called - transport to hospital

· Client has high temp - 103 - and is intubated at hospital

· Client has no pulse -atropine administered - pulse not regained. Client pronounced dead

Post Death Actions

Post Death Actions: Results/Outcomes

· Regional mortality finds care appropriate - states client lived beyond life expectancy given medical problems

· Had a DNR one year prior - in hospital and on life support-- but that DNR had been removed

· Region recommends to close case

· State mortality review examines case, despite being closed at region

Program Review Committee Staff Comments

· Not sure why this case was selected for story in Hartford Courant except this client lived at home where a number of the deaths had occurred

Demographics

Cause of death: Acute subdural hematoma

Events Leading to Death

· Client lived in group home for six years

· Had Parkinson's disease

· Few months prior to death taken to hospital ER by ambulance; client had slurred speech and confusion

· Client had increasing falls - one fall resulted in fractured ribs

· Many incident reports related to falls

· A few days prior to death fell and had a nosebleed

· Day before death fell away from home but was able to walk back home with assistance

· Day of death staff noticed a facial droop and slurred speech.

· Client taken by ambulance to ER - client admitted

· Client continues to deteriorate - CT scan reveals subdural hemotoma w/pressure on brainstem

· Discussions with family, client "virtually brain dead"; decide on no surgical intervention, put DNR in place

· Died 4 days later

Post Death Actions

Post Death Actions: Results/Outcomes

· Regional Mortality Review finds - given Parkinson's and increasing falls-should have been seen by a neurologist

· Regional mortality recommends better monitoring/tracking of falls for clients in region

· Due to falls 3-4 days before death -should have had an ER/neurological evaluation

· State mortality review agrees that a neuro-evaluation should have been done

· State mortality review states regional Health services director to submit a regional process for risk assessment and tracking of falls

Program Review Committee Staff Comments

· Region states, in response to committee staff inquiry, that the proposal of a tracking system was brought to "treatment team" and it was decided it would not be appropriate for a majority of clients and that it could be addressed on a case-by-case basis in quarterly nursing assessments. (Committee staff thinks that would have been the system that would have been in place at the time of the client's incidents and death - not sure what the change would be)

· Not clear from the file what the client's IDT knew about client's increasing falls and how this was addressed in plan.

· DMR indicates in write-up that only minor injuries were sustained in client's prior falls -yet one resulted in fractured ribs

· DMR has instituted a new risk assessment procedure which will evaluate a client's mobility, this may address issue of clients with increasing falls

Demographics

Cause of Death: 1) Respiratory failure; 2)Aspiration 3) Hypotrenia

Events Leading to Death

· Client had lived in home for 3 years;

· Client very medically involved - blind, seizure disorder, incontinent, chronic edema, and difficulty swallowing

· Client taking a diuretic for edema

· Client had eating guidelines;

· Client had change in mental status following a seizure

· Taken to internists then brought to ER

· Client admitted - with acute renal failure, UTI, hypotrenia

· Endotracheal tube, gastric tube and foley catheter inserted

· Seemed to be doing ok, diet planned and meds changed

· Client began vomiting, deteriorated; client moved at to ICU CPR initiated twice and revived

· Third time unsuccessful - client expired

Post Death Actions

Post Death Actions: Results/Outcomes

· Death report indicates hospital autopsy performed

· Regional mortality review cites should have been better communication between group home staff and hospital especially around choking

· State mortality review indicates might have been good to measure fluid intake and output, but because of client's incontinence this would have been impossible

· Cites a problem with hospital transcription - one place "hypertrenia" and in another "hypotrenia"

Program Review Committee Staff Comments

· Not clear whether client had a choking episode in hospital

· Not sure where Hartford Courant obtained cause of death -different cause of death than committee staff saw on any document in file

· Communication issue - DMR not notified of hospitalization

· Regional mortality review to send letter to private agency regarding communication-staff to hospital, staff to DMR, saw no letter in file;

· Not clear whether autopsy done - death report indicates yes, RMRC indicates none; none in file

Demographics

Cause of Death: Asphyxiation by Submersion

Events Leading to Death

· Client had lived at CLA for 15 years. The client was taking a bath one afternoon in the attendance of a direct care staff person. The staff person left the client unattended in the bathtub while the staff person went to find a towel. While unattended, the client, who had a known seizure disorder, had a seizure and drowned.

· The client was found submerged by the staff person, who administered CPR and told another resident to call 911. 911 responded

· When the death occurred, there was only the one staff person on duty, with a total of six residents.

· The client's individual plan indicated client was not to be left alone in the bathroom, and the staff person had been trained and was aware of that requirement.

Post Death Actions

Post Death Actions: Results/Outcomes

· Abuse/neglect investigation conducted by provider, found the staff person had committed neglect by leaving the client unattended in the bathtub. Staff acted contrary to training without good cause. Recommended provider decide about continued employment of staff person, and that bathing protocols should be reviewed with all staff.

· Local police investigation led to staff person's arrest for second degree manslaughter, and ultimate conviction.

· DMR Safety Alert issued two days after client's death to all DMR and Private Agency Directors on Bathing and Personal Care (Three weeks before, another person drowned unattended in a bathtub at another CLA). Required immediate review of agency protocols and individual procedures, including staff training, to ensure individual needs/supports during personal care are met, including bathing. Documentation was required to be sent to DMR within nine days.

· OPA agreed with neglect finding; sought evidence of follow-up to safety alert.

· Regional Mortality Review found supervision inappropriate; "found" 1:6 staff/client ratio, and that staff recently decreased to 1 on Sundays; was aware police investigation ongoing.

· State Mortality Review Board agreed with abuse/neglect investigation report recommendations.

· DMR Root Cause Analysis led to many systemic recommendations, including Risk Screening Assessment

Program Review Committee Staff Comments

· Clear staff should not have started bath in first place, but some other emergency could have come up unduly distracting one staff, creating risk for client. Local police report noted client's parents, who were very involved with their child, had an understanding with the provider that at least two staff would be on duty at all times due to their child's medical issues.

· Issue of past staff problems

Demographics

Cause of Death: 1) Hypoxic encephalopathy with survival in coma; 2) airway obstruction; 3) aspiration of food

Events Leading to Death

· Client lived at home for three years

· Client was at day program away from her group home and choked while eating a sandwich for lunch.

· Staff tried Heimlich and called 911.

· Client died next day at hospital.

Post Death Actions

Post Death Actions: Results/Outcomes

· Regional mortality review concerned that sandwich client was eating not consistent with her mechanically ground diet order; residential notes not comprehensive; day staff responded appropriately, but regional committee not sure Heimlich done correctly; Referred for state level review

· State Mortality Review Board noted diet orders not clear; use by hospital of "mechanical soft" versus "ground" consistency

o Requested CLA provider to send policies and procedures regarding dysphasia policy and general handling of dietary needs; explain earlier removal of feeding tube a year earlier.

o Accepted response (see below), but diet consistency definitions remained. Noted DMR Nutrition Workgroup working on diet definitions

· Provider responded to state mortality review board noting client's diet was consistently ordered as "mechanical soft", and ham and cheese sandwich could be consistent with "mechanical soft". Client never diagnosed with dysphagia. A feeding tube had been in for specific period of time after client had stroke, but determination was made client could return to eating on own.

Program Review Committee Staff Comments

· In provider's documentation, "mechanical soft is used for clients who can swallow without difficulty but have problems chewing. All foods must be able to be fork mashed."

· Case revealed issues with common food consistency definitions.

Demographics

Cause of Death: 1) Seizure Disorder; 2) Obstruction of splenic flexure of colon

Events Leading to Death

· Client had lived at home for three years before his death; client was in good health, with his biggest concerns being behavioral, including self-injurious behavior.

· In the early morning hours of the day client died, client was awake, hyperactive, and very vocal. Around noon that day, he refused lunch, was thrashing on floor with helmet on, and took Tylenol for discomfort. A nurse was notified

· Later in afternoon client's stomach was very distended; client ate nothing for dinner, and appeared uncomfortable.

· The nurse assigned to the home (CNC) was called, but not at home. CLA staff called DMR nurse at the regional center, who advised over the phone to give client a fleet enema.

· In early evening client went into seizure. Regional center nurse called again, who told staff to call 911. EMTs responded and took client to hospital; all care measures taken, but client died about an hour later.

Post Death Actions

Post Death Actions: Results/Outcomes

· Regional mortality review committee found overall health care management excellent; but client's behavior was clearly escalated and signs and symptoms significant, but CLA non-nursing staff not able to link what they saw to emergency situation until seizure, despite training in observational skills and emergency response

· Had systemic concern about nurses providing care instructions over the phone for clients they have not evaluated or do not know

· Recommended training for staff regarding GI implications for clients prone to GI problems; region and DMR central office should develop clear written directions and expectations for nurses who serve as non-nurse staff resources.

· State Mortality Review noted MD should have been called sooner; recommended region should issue advisory to act quicker in emergencies

· Systemic issue of nurses responding to telephone inquiries to be discussed with regional directors of health services

Program Review Committee Staff Comments

· A memo went to regional nursing staff soon after state review instructing nurse to be extremely conservative in their phone directions; if a nurse cannot assess a client, instructions should be limited to seeking evaluations. Non-nurse staff have authority to make necessary decisions.

Demographics

Cause of Death: 1) Respiratory Failure; 2) Aspiration

Events Leading to Death

· Client had just moved to public CLA five days before death, because it had 24 nursing care. He moved from a private CLA where he had live for 16 months. Before that, client had lived in a nursing home for 14 years.

· For year and half before death client was admitted several times to emergency room for many reasons, including pneumonia and seizures.

o Client had feeding tube put in five months before death due to a positive test for aspiration.

· Three months before death, client's team discussed client's declining health and need for increased nursing services, which led to the transfer days before client's death.

· Two to three days after client's transfer, client became congested and had respiratory problems.

· 911 was called, client taken to hospital, treated with full code, but client died.

Post Death Actions

Post Death Actions: Results/Outcomes

· Regional mortality review found private CLA provided excellent care and recognized his need for increased nursing coverage, leading to transfer to public CLA with 24 hour nursing. Staff at that CLA responded quickly and appropriately the day client died.

· State Mortality Review Board accepted local findings; no further recommendations

Program Review Committee Staff Comments

· Unclear why this death was considered questionable by media.

Demographics

Cause of Death: Traumatic asphyxia due to exclusion of air

Events Leading to Death

· Client had lived at regional center for 18 years.

· One night DMR staff put conditioner on client's hair, covered hair with a plastic bag tied at the back of head and put client to bed

· Client had limited use of arms

· About an hour after going to bed, client was found by staff with the bag over client's face, and was asphyxiated. Staff tried CPR, chest compression and mouth-to-mouth breathing. 911 was called, but client was dead on arrival at hospital.

Post Death Actions

Post Death Actions: Results/Outcomes

· Abuse/Neglect investigation conducted by DMR staff; found staff neglect was substantiated based on staff putting a plastic bag on client's head for overnight when she was unattended, and another staff for not coming to client's assistance immediately.

· Two persons were terminated, one suspended.

· The regional mortality review committee found problem with personal care leading to accidental death of traumatic asphyxia; found systemic issues: identified improper use of materials (plastic bag) in hair care; failure in supervisory judgment in allowing improper use of material; possible delay in provision of emergency resuscitation. Recommended memo from management to staff on safety/common sense issue of hair care; regional review of all hair care practices in all DMR operated facilities

· State mortality review committee accepted regional findings and investigation findings that substantiated neglect. Recommended DMR should consider sending statewide notification about need for caution when doing using/using head coverings appropriately

· OPA agreed with DMR investigation neglect substantiation

· State and local police investigation did not lead to arrest based on state's attorney determination there was no criminal liability or intent related to the death.

· Jury awarded $1 million verdict in wrongful death case.

Program Review Committee Staff Comments

· Assigning director of regional center to investigate appears to be a conflict.

Demographics

Cause of Death: Asphyxia due to airway obstruction

Events Leading to Death

· Client had lived at his CLA for two years.

· Client was eating a peanut butter sandwich as a late night snack, prepared by a staff person.

· He began to choke on sandwich, staff did Heimlich and called 911.

· EMTs came, made efforts including a tracheotomy, but client died on way to hospital.

Post Death Actions

Post Death Actions: Results/Outcomes

· Injury/Unknown Origin investigation conducted by DMR; found no neglect; noted, though, client's episodes of choking/vomiting while eating not well documented in staff running notes and client's IDT never discussed issue, didn't set up data collection to monitor his aspiration risk with eating special eating program; also noted problems with documentation and staff ability to communicate at home because of separate apartment configuration.

· Recommended any resident determined to be at risk for aspiration be formally evaluated and a clearly defined dietary/feeding program established.

· Regional mortality review committee found medical and personal care prior to death timely and appropriate; but events leading up to death not accurately reflected/documented in residential records; records indicate client was inappropriately placed in supervised apartment program and he did not have a program.

· State Mortality Board accepted regional findings and recommendations including investigation recommendations.

· OPA disagreed with DMR finding of no neglect and substantiated neglect by DMR for failing to generate feeding guidelines to maintain his health and safety based on evidence in DMR investigation

Program Review Committee Staff Comments

· DMR investigators didn't interview DMR staff until 6 days after incident.

· Question of programmatic neglect: attention to client's eating habits

· When OPA disagrees with DMR conclusion about neglect, unless DMR disputes the finding, OPA assumes its finding is the final disposition. DMR CAMRIS does not report OPA finding.

· Client had mental illness for which client took many medications, and was episodic. When stable, client could provide own basic life skills independently, although he had eating behaviors; when not, he required close supervision.

Demographics

Cause of Death: 1) Pneumonia; 2) Right Lower Lobe Lung Abscess; 3) Inhalation from dementia from Down Syndrome

Events Leading to Death

· Client had been at nursing home for seven months. Before that, client had lived at a private group home for just three to four months after living at another home for three years.

· In the last 3-4 years, client, who had Down Syndrome, began to show signs of Alzheimer-like dementia. Client also began having significant pulmonary conditions, and there was discussion about surgery.

· Client's guardian did not authorize surgery due to problems with narcotics used for an earlier surgical procedure, which exacerbated her mental confusion. At the same time, a DNR was put in place with the consent of her guardian and after discussion with the DMR director of health services. Client then was moved to the nursing home.

· Seven months later, client was admitted to hospital and died a day later.

Post Death Actions

Post Death Actions: Results/Outcomes

· The regional mortality review found death was anticipated; medical and personal care appropriate; no systemic issues identified.

· State Mortality Review Board accepted local findings; no further recommendation (did note that DNR form not included with MQAB packet, but knew that DMR was involved/aware of decision.

Program Review Committee Staff Comments

· Question why regional review done so long after death (2 years).

· Unclear why this would be considered questionable death by media.

Demographics

Cause of Death: Asphyxia by Food Bolus

Events Leading to Death

· Client had lived at home for seven years; he had habit of trying to get food he wasn't supposed to have, because of his diabetes. He had no teeth and was on a ground diet.

· One afternoon for about a 15 minute period, while all three staff were attending four other clients/activities in other parts of house, client took a raw pork chop from refrigerator, and attempted to eat it.

· Client choked and fell. Staff heard him fall, attempted the Heimlich maneuver, and called 911. At hospital, client remained unresponsive for three days, family requested DNR, and he died.

Post Death Actions

Post Death Actions: Results/Outcomes

· Abuse/Neglect investigation conducted by DMR staff substantiated neglect on the part of the provider; provider failed to provide client with adequate care and supervision to ensure his safety, and direction to staff to provide adequate care and supervise all residents; provider failed to bring staff request to prevent access to food to Human Rights Committee in light of diabetic condition and risk of choking; recommended increased communication about and familiarity with client needs on the part of provider supervisor and staff be aware of their role in care of individual clients.

· Also recommended DMR develop process for case managers and contract monitors to work together in home oversight, more clearly define roles and systems to resolve problems, use a formal programmatic transition process when a home changes providers, give more detail about client needs in profiles in RFPs, and be careful grouping ambulatory persons with those needing greater levels of care.

· Regional Mortality Review found medical care appropriate; personal care was not (cites A/N investigation);recommend review by state mortality board.

· State Mortality Review closed case

· Wrongful death lawsuit filed and settled in 2002 for $500,000.

· Changes provider made included clarifying procedure for staff to "hand off" client supervision; identify two specific clients for each shift that a staff person is responsible for; and more screening for choking. (Provider had had unwritten protocols for staff to know where client was, keep counters clear, cover things in the refrigerator.)

Program Review Committee Staff Comments

· It does not appear DMR required provider to respond to how it would address investigation findings.

· Program review staff could not determine how DMR responded to the recommendations directed toward the department.

· Although client had lived in home for several years with the same housemates, when the client died, the provider had run the home for a year and a half. According to the provider, the major concern about the client and his getting at food was because of his diabetic condition; a choking incident that occurred 10 years earlier before the client moved to the home was not mentioned in any material the provider saw prior to taking over the home or after. In the months before client's death, there were episodes of food stealing, although the record as to how client's IDT or the provider was addressing the behavior is unclear, but looks minimal. Also unclear was if and how the possibility of locking the refrigerator was considered as a solution to promote client's safety, given the differences in mobility and need for assistance among house members.

Demographics

Cause of Death: Cardiac Arrest; Acute haloperidol toxicity

Events Leading to Death

· Client had lived at CLA for seven years.

· Client had mental illness, took medications for it, and had been hospitalized in past. A couple of weeks before death, client had increased behavioral symptoms and was admitted to a hospital psychiatric unit under client's psychiatrist's direction.

· A few days after admission, client was transferred to another hospital's psychiatric unit. Behaviors did not improve and medications increased and new ones added.

· Eight days later, client was found unresponsive, no pulse and no breathing. Full code was called, but no cardiac activity seen; pronounced dead.

Post Death Actions

* restricted by family-could not do brain.

Post Death Actions: Results/Outcomes

· Regional Mortality Review found psychiatric care at hospital of concern; numerous changes of medication; use of medications on an as needed basis; concern about unresponsiveness of hospital staff to group home staff's concern about client appearing overmedicated. Sent to state level review

· State Mortality Review concerned about care, especially the use of Haldol on an as-needed basis; questioned hospital use of restraints; sought expert opinion from independent psychiatrist on medication question and then referred question of care to Department of Public Health for its review.

· Expert noted limitations of review due to limited autopsy consent by family; could not examine central nervous system; raised questions about documentation of medication use and its effects, along with levels, but could not clearly read M.D. notes so couldn't make definitive conclusion; client pre-death blood lab report was not available to expert.

· State mortality review referred case to DPH

· DPH found regulatory violations related to documentation of medication use.

Program Review Committee Staff Comments

· Final determination was that level of Haldol in blood was within therapeutic levels, thus no toxicity

Demographics

Cause of Death: Cardiopulmonary arrest due to subdural hematoma

Events Leading to Death

· Client had lived at CLA for four years, and was moved to a nursing home less than two weeks before client died

· Move was due to inability to perform self-care skills independently, increased confusion, stubbornness, and forgetfulness, impaired balance and falls, and onset of dementia (possibly Alzheimer's, related to Down Syndrome).

· Admitted to hospital four days before death due to increasing unresponsiveness and congestion requiring suction; CAT scan of head revealed subdural hematoma

· Guardian/family did not consent to proposed surgery.

· Day before death DNR was obtained with consent of family because outlook not good; not responsive; very congested

Post Death Actions

Post Death Actions: Results/Outcomes

· Regional mortality review answered "unknown" to question of whether medical/personal care was timely and appropriate; questioned if hematoma caused by fall, noting no recent fall recorded in records; noted if had a fall, with a head injury, it should have been evaluated at hospital immediately; outcome might have been different with timely treatment; wondered why CAT scan ordered

· State Mortality Review found care appropriate; case closed

Program Review Committee Staff Comments

· Client was admitted to hospital from group home for evaluation because client's caregivers believed he was no longer safe in a group home, according to hospital discharge summary

o Cannot tell from state review report what if any discussion there was about issue of possible fall as the cause of the subdural hematoma

· Query if the regional review committee attempted to answer the fall question it raised

· Unclear how state mortality review board addressed hematoma question

Demographics

Cause of Death: 1) Cardiopulmonary Arrest; 2) Chronic Obstructive Pulmonary Disease; 3) Recurrent aspiration pneumonia

Events Leading to Death

· Client had lived at the group home for six weeks, moving from MTS where he had lived for 27 years. He had used a feeding tube for 11 years for all his nutrition and medication.

· In month before client died, he had increased seizure activities, elevated temperatures, and respiratory problems.

· Client was admitted to the hospital by client's primary care physician's order to treat the respiratory ailment that was not responding to outpatient care. Two days after admission, the client had a cardiac arrest, was resuscitated, and sent to intensive care. There he had a multi-system failure, a DNR order was put in place, and he died after four days in hospital.

Post Death Actions

Post Death Actions: Results/Outcomes

· Regional Mortality Review found care was appropriate and nursing care at MTS and at home was loving, supportive, and probably contribute to client living as long as client did; found systemic issue that guardianship should have been pursued several years ago with a client this frail, and funeral planning should occur as part of OPS process

· State Mortality Review Board accepted local findings

· The autopsy found no single cause of death, but pointed to multi-system failure.

Program Review Committee Staff Comments

· Client's terminal condition was discussed with the Office of Attorney General and OPA. Probate Court appointed guardian while client was in hospital

· Unclear why death would be considered questionable by media