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The surveillance video captured the fatal blow to James "Milt" Ferguson's 91-year-old senior specialist, saying it could have been avoided.
UNITED STATES TODAY & # 39; HUI
Jim Ferguson wanted answers.
How was his 91-year-old father, who served in the US Navy during the Second World War, fatally wounded in a veterans care home, the institution that Ferguson had entrusted for his care? To take care of him?
Surrounded by a computer screen with VA officials from Des Moines, Iowa, Ferguson watched a video surveillance in the hallway describing a terrible blow to his father's head.
"I lost it," Ferguson told USA TODAY. "I've cracked it."
In the video, James "Milt" Ferguson's father, demented and blind right, seems confused. He opens a corridor door, rolls his wheelchair into another resident's room, and then comes out again. No staff member is visible. He turns around and returns to the room.
Halfway through the door, her chair turns back. Milt Ferguson crushes on the ground and lands at the back of the head. Ferguson stated that he had learned that the chair had been moved by the resident who was in the room, which we did not see in the video. While staff members rush to help him, Ferguson can turn around and sit down, but the impact causes massive brain bleeding that will kill him in a few days.
What would later turn the son's despair into indignation was what he had learned about the events that led his father to go round in a circle unattended last December and what had happened. after he crashed to the ground.
"It's like my dad was dead in their hands," Ferguson said.
A surveillance camera filmed the deadly injury of James Ferguson Sr. in a retirement home of the Department of Veterans Affairs. Warning: the footage can be disturbing.
UNITED STATES TODAY & # 39; HUI
Many nursing homes across the country, including the one where Ferguson was being cared for, posed serious health problems for residents.
USA TODAY reported in March that the inspections conducted by a private contractor hired by the VA revealed deficiencies that had caused "real harm" to veterans in more than half of the 99 VA homes examined. Inspections revealed inadequate supervision or unsafe conditions for 53 of them.
In Des Moines – which received the lowest star out of five in the VA's own ratings, based on surprise inspections – inspectors found that managers did not ensure that staff treated residents with dignity or dignity. does not comply with basic infection prevention and control measures.
James "Milt" Ferguson Sr. remember. (Photo: Family photo)
The story of what happened to James Ferguson in Des Moines provides a more detailed picture of the care received by an elderly veteran. The medical records provided to the US today by his son and legal guardian describe what the experts described as a series of disturbing decisions made by VA staff, before and after his deadly head injury.
Nine days earlier, VA caregivers had determined that Ferguson was a danger to himself and others because his dementia had made him wander, agitated. They had him in individual and continuing observation with an assistant, but had removed him from strict supervision when he had entered the retirement home. There, the staff did not reinstate the increased observation, although it was several times lost dangerously in the rooms of the other residents.
After his injury, the staff put him back in his wheelchair but did not report the incident to a supervisor for 40 minutes, indicated the surveillance recordings and video. Ferguson was not transported to an emergency room for two hours after that. Then it took another two and a half hours to send her to a trauma hospital. The timestamp on the video shows that the fall occurred at 3:49 pm. and it was not until shortly before 9 pm that Ferguson was transported to the trauma center.
& # 39; A disaster waiting to arrive & # 39;
Specialists who reviewed Ferguson's medical records at the request of USA TODAY expressed concerns about the quality of his care.
"It was definitely an impending disaster, and it happened," said Robyn Grant, director of public policy and advocacy for the National Consumer Voice for Quality Long-Term Care, a health organization with non-profit advocacy based in Washington.
"I'm really struck by predictability with her repeated episodes of going to other people's rooms," she said. "They should have had an intervention to provide him with adequate supervision and to solve the problem of wandering."
Grant added that the time it took later to properly assess and diagnose the severity of his injury and take him to a trauma facility also raises questions. "What was going on there, in terms of delays?" she says.
VA retirement homes: Federal government denounces "flagrant disregard" for veterans' safety
Richard Mollot, executive director since 2005 of the Long Term Care Community Coalition, a non-profit advocate for the improvement of nursing home care in New York City, said the gaps indicate that there are had "most likely" a lack of qualified or sufficiently trained staff to meet his needs. Needs.
"The benefit of finding yourself in this environment is that you benefit from skilled nursing care and adequate supervision," he said.
Mollot said the reporting deadline is particularly worrying. "How many times does it happen that no one is watching? It's what's so upsetting."
"All staff acted correctly"
A spokesman for the Des Moines VA, Timothy Hippen, said in a statement that a review after the "untimely death" had concluded that "all staff had acted properly".
"Whenever an unexpected death occurs, the VA Central Iowa Health System reviews its policies and procedures to see if changes are warranted," he said. "We did it here, finding that all the staff had acted correctly."
It's the nursing home of the Monk veterans where James Ferguson's 91-year-old father was fatally injured. (Photo: Brian Powers, USA TODAY network)
In response to questions about the case, VA spokesman Curt Cashour accused the United States today of focusing on "isolated complaints" and "choosing the experiences of a handful of veterans to give the impression of a vast problem.
Cashour has maintained that, overall, VA retirement homes "closely compare" with non-VA institutions. Each year, more than 40,000 veterans call on the institution's 134 institutions.
USA TODAY reported last year that near 70% of VA nursing homes scored lower than non-VA care homes, with the majority of quality indicators monitored by the agency, which include rates of infection, severe pain and bed sores.
Hippen refused to answer detailed questions about Ferguson's case.
"We will not deal publicly with the details of this case, but we have been in direct contact with the family of the veteran to discuss their concerns," he said.
Jim Ferguson said he remained upset even though VA officials had shared the surveillance video with him and that they were sorry about what had happened to his father.
He wants the VA staff to be held responsible. He wants to make sure that policies are in place so that it does not happen to anyone.
"Nobody should live his life like that and have what happened to him at the end," he said. "I want it to be the last person to whom it happens."
A player called "booger"
Even as his dementia got worse, Milt Ferguson flashed his young age.
The old deckhand of the heavy cruiser United States Pensacola was affectionately known as the "booger" at the Des Moines Register, where he worked at newspaper sales for 23 years before retiring in 1995. He enjoyed playing slot machines and horses.
A family album shows a photo of James "Milt" Ferguson Sr., second from the right, during his years in the Navy. (Photo: Brian Powers, USA TODAY network)
On a note from her medical record, a nurse practitioner wrote, "The patient laughs when his nickname is mentioned." Jim Ferguson had come for a visit that day, as he did almost every day. "He smiled and seemed to enjoy his son's company," says the medical record.
The decision to put him in a retirement home was a heartbreaking decision, Ferguson said. He moved into his parents' home and worked for three years. But in April 2018, her mother died. He said that a VA social worker had told him that his father needed more intensive care and supervision, 24 hours a day.
"They gave the impression that, well, if he was hurt, I could be charged with a crime," Ferguson said. "So when I decided to put him in a retirement home."
"His dementia was acting"
Ferguson transferred his father to the Bishop Drumm Retirement Center, a private facility located just outside Des Moines, where his mother worked as a nursing assistant at the Alzheimer's unit for over 20 years before taking his retirement.
The center welcomed Milt Ferguson last August. But three months later, her condition worsened.
"The day before Thanksgiving, I received a call from Bishop Drumm, his dementia was worsening," said his son.
He hit two staff members, was "restless all day" and "wandered around the other residents' rooms, causing distress," noted a nurse in his medical file. "He's usually" nice "so that's a difference from his usual behavior."
Ferguson was transported by ambulance to the VA Medical Center in Des Moines, where he was admitted to the acute psychiatric ward. He was placed in individual observation with a caretaker – an assistant instructed to intervene when he whipped or tried to enter the other patients' room.
They adjusted his medication and, after some aggressive seizures, he seemed sufficiently calm after three weeks to be transferred to the nursing home for VA located on the campus of the medical center.
But there was a problem, wrote in his file a psychiatric nurse: "Veterans are not warned of the child there".
& # 39; Helped me helped me & # 39;
After a probationary period of 22 hours without a guardian, Milt Ferguson moved to the VA Care Home.
The problems started in a few hours.
He was hardly sleeping, hallucinating, shouting "Help me, help me" again and again. He was agitated and, once again, he "came in and out of his peers' room", day after day, writes the nursing staff.
They gave him medicine. Sometimes he calmed down. Sometimes he did not do it.
A psychiatrist was managing his case remotely. According to public reports, the doctor reportedly worked at a Virginia treatment center a few hours later in Lincoln, Nebraska. At virtual appointments, the psychiatrist advised to change Ferguson's treatment.
On December 19, a week after the installation of Mr. Ferguson, the staff at the retirement home found that he was still restless and anxious, walking, screaming and screaming. His care team – psychiatrist, primary care physician, nurses and social workers – met to discuss the case.
The psychiatrist said that a review of his records had revealed "increased confusion with wandering" over the past week. The doctor prescribed higher doses of a mood-stabilizing medication and a sedative. The records show that there was no discussion about closer monitoring or reinstatement of an individual observation.
"We will ask RN to contact this doctor in a week with an update," the psychiatrist wrote.
From here, Ferguson would be dead.
"A big piece of golf ball"
On December 20, when two assistants rushed to help Milt Ferguson, head on the floor and legs crumpled to the side, the clock's video surveillance hallway indicated 3:49 pm. But in a report completed an hour later, a nurse recorded the time of the accident at 16:30.
His records do not indicate what the staff did with Ferguson over the 41 minutes, other than putting him back in his wheelchair.
At that time, he had "a size the size of a golf ball on the back of his head". The nurse informed the service manager, a nurse practitioner, who wrote at 5:06 pm. that & # 39; it ordered an immediate scan of his head.
This did not happen until around 6:30 pm, when Ferguson arrived at the emergency department of the medical center on the Des Moines campus, on a bed led by a caregiver. The assistant said that Ferguson had already been mistaken for a scanner, but that he was not cooperating.
A doctor in the emergency room quickly administered a sedative and the analysis was completed. At that time, the veteran of the Second World War had a "significant bleeding" at the right back side of the brain, which was so acute that the scanner had told him that his brain had shifted to the left in his skull.
Sent to scan
The doctor informed the MercyOne Des Moines Medical Center, a trauma hospital, at 7 pm For nearly two hours, the doctor tried to keep Ferguson comfortable and control his blood pressure until an ambulance arrived. He then went to Mercy at 8:55 pm.
The doctor also continued to call Ferguson's son, leaving voice messages.
But Jim Ferguson had himself been admitted to a hospital and provided the VA retirement home with a consent form allowing staff to contact a close friend if anything happened to his father. This form was sent to "scan" this morning.
When Jim Ferguson picked up all the voicemails, he rushed to Mercy the next morning.
"He was not receptive, he was lying on his bed and making that horrible noise as they sucked his saliva," he said. "I have never even been able to say a last word to my father."
He died the next day.
Specialists who reviewed the case at the request of USA TODAY pointed to several deficiencies in its VA care that could have affected the outcome.
Grant, director of national consumer voice policies for quality long-term care, said the 22-hour test of the absence of babysitter was "not enough time to establish how it was going to."
When he then acted day after day, in agitation and confusion, they should not have allowed him to walk around other residents' rooms, she said. Such situations can provoke fear or distress among other residents and "provoke an altercation, violence or radiation".
"It could be argued that this could have been avoided," she said. "There should have been somebody, somewhere, who could have seen that happening and – especially when he drove – came in and interjected:" Let me t & rsquo; Help, let's go to your room. "
Mollot, executive director of the Community Coalition for Long-Term Care, said that adherence to standards of care meant that staff identified risks and needs, as well as ways to respect and mitigate them, and did so. then consistently.
"It's exactly the kind of thing that happens when these standards are not followed," he said.
& # 39; A place on & # 39;
The spokesman for the VA Des Moines, while refusing to answer detailed questions about what happened, said that, in general, "taking care of nursing home residents involves finding a balance between the independence of the patients and the need for surveillance, where appropriate ".
"While careful review and limitation of residents' activities and freedom of movement could potentially reduce the risk of adverse events, this would seriously affect the quality of life of patients, which we are trying to preserve. as long as possible, "he said.
Jim Ferguson still has his father's wheelchair in the garage. He keeps the sweatshirt worn by his father when he last used the chair. Ferguson has retained the services of a lawyer, Brad Biren, to help determine next steps and determine how to hold the VA accountable.
"Someone did not look at my father and let him die," he said. "It's supposed to be a safe place."
More: Secret assessments of retirement homes conceal poor quality care to the public
More: Most nursing homes in Virginia host more residents with bed sores and pain than private institutions
More: Bedsores, Neglect, Alleged Abuse: In nursing homes of inferior quality to VA
More: "It's nothing horrifying: veterans' groups are demanding solutions at VA retirement homes
More: Inspections reveal veterans injured in retirement homes in 25 states of Virginia
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