Facility left sick man alone

Unlicensed owner ran errands

resident died

Sun Follow-up

June 07, 2008|By Tanika White | Tanika White,Sun Reporter

Caregivers at an unlicensed assisted-living facility in Northeast Baltimore left an ailing 50-year-old man unsupervised for hours shortly before his death, according to a report by state health investigators, whose findings were sent last week to the Maryland attorney general's office.

On May 1, the day Donald F. Matthews died in the early morning hours, police looking into his circumstances discovered that another resident of the group home needed attention. They sent him to a hospital for treatment of an infected bedsore "after police noted an odor," state documents said.

The Sun published an exclusive report last month on Matthews' death and subsequent state actions. The remaining five residents were removed by Adult Protective Services. The Office of Health Care Quality shut down the home in the Lauraville neighborhood and fined its operator, Sadie Mae Handy, $10,000 for operating an assisted-living facility without a license.

"Our remedies are limited" when it comes to punishing operators of unlicensed facilities, said Wendy Kronmiller, director of the office, which is a part of the Department of Health and Mental Hygiene

"I think at this point we've probably crossed over into a more serious case against this provider," said Kronmiller, whose office licenses and certifies most types of health care facilities.

She said she has turned over the findings to the attorney general's Medicaid Fraud Control Unit, which investigates reports of abuse and neglect of vulnerable adults in Medicaid-funded facilities and assisted-living facilities - even if those facilities do not receive Medicaid funding.

Assistant Attorney General Catherine Schuster Pascale confirmed receipt of Kronmiller's report but declined to comment about the findings. She did say, however, that a person can be criminally prosecuted for "intentionally failing to provide essential medical treatment, supervision or services to a vulnerable adult." That is defined as an adult who requires assistance with medication, dressing, hygiene or other basic needs.

After Matthews' death, state health investigators sought to determine what had happened to the formerly homeless man, who came to live in the group home at 2909 Halcyon Ave. in December.

Matthews, who had mental disabilities and diabetes, seizures and bipolar disorder, was released from Maryland General Hospital to his room in the home on April 30, according to state health department documents.

Paramedics were called to the house several hours later, and, according to police reports, Matthews was pronounced dead at 1:41 a.m. Officials are awaiting results of an autopsy.

Health department investigators found that Handy, the home's operator, left Matthews in the home without supervision while she ran errands, according to the report. According to the report and Handy, Matthews had a "terrible cough" and breathing problems, which prompted her to take him to the emergency room at Maryland General. Handy told investigators she was concerned that the hospital had released him too quickly.

"Her response to her worrying about him was to leave this patient, a resident, alone with another resident for a period of time," said William Vaughan, chief nurse of the Office of Health Care Quality. "That speaks volumes about her judgment."

Neither Handy nor a spokeswoman for Maryland General Hospital responded to requests for comment.

According to state regulations, staff members in an assisted-living facility are required to be present whenever residents are there. Documents show that neither Handy nor the house manager, Karl Williams Sr., was on site for at least two hours, possibly longer.

State documents indicate that Matthews "was left without staff supervision during which period he experienced a medical emergency. Staff were not available to monitor the resident and provide appropriate interventions."

According to records, about 12:30 or 1 a.m., Williams said he discovered Matthews unresponsive in his bed, bleeding from the mouth, and called 911.

Williams told investigators that Matthews apparently fell and broke a nightstand while he and Handy were gone. He said he found the nightstand "shattered and lying in pieces on the floor," according to documents.

Williams could not be reached for comment.

"It's easy to surmise in this case that, because there was something broken, that there would have been a noise and help would have arrived more quickly if there had been staff in the house," said Kronmiller.

The other resident who required care, a 50-year-old man who was not named, had an infected bedsore on his buttocks.

"It required treatment and surgery," said Vaughan, the chief nurse. From that, "one can draw a conclusion about the level of observation that was going on there," he said.

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