Death tied to actions of nursing home staff

Revised autopsy report says woman, 89, died as a result of overfeeding

October 07, 2003|By Walter F. Roche Jr. | Walter F. Roche Jr.,SUN STAFF

The state medical examiner has issued a revised autopsy report on an 89-year-old nursing home patient who died after being fed to death last year, directly attributing the woman's death to actions by employees of the Northwest Baltimore facility.

The amended report concludes that Bertha Small, a patient at Villa St. Michael Nursing and Retirement Center, died of asphyxia resulting from overfeeding. The initial report, issued shortly after she died Nov. 16, listed heart disease as the cause.

The initial report indicated that the death was "natural"; the new one lists it as "accidental."

Small died after personnel at the nursing home left a feeding tube running continuously until the liquid exploded from her body.

"This 89-year-old African American female died of asphyxia due to overfeeding," the new autopsy report states.

Though Small was in obvious distress, the report notes, employees of Villa St. Michael, at 4800 Seton Drive, failed to notice it or take action "until early morning when her abdomen was markedly protuberant and she was short of breath and moaning."

According to the report, the true cause of death was not found during the initial autopsy because much of the liquid from the feeding tube had been suctioned from the victim's body during a resuscitation effort.

The amended report was issued Sept. 30 and signed by Assistant State Medical Examiner Susan Hogan and Chief Medical Examiner David Fowler.

Small's family sued the nursing home this year, seeking $5 million in damages. Andrew Slutkin, the attorney for the family, declined to comment on the case, which court records indicate is pending.

Owners of the nursing home could not be reached yesterday for comment.

Details surrounding Small's death became public after an investigation by the state Office of Health Care Quality.

That investigation found that Small's feeding tube was left running from the evening of Nov. 15 until the next morning. More than eight times the amount of liquid than had been prescribed by her doctor was pumped into Small's 89-pound body.

State inspectors also noted that the feedings were not supposed to begin until Nov. 16.

State officials first fined the nursing home $7,500, then imposed an additional $20,000 penalty as part of a settlement agreement that involved other violations of state and federal regulations.

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