A
retired judge was supposed to receive antibiotics for a hip infection.
He didn't get a single dose. Masonic Homes of Kentucky didn't tell his
widow.
by Andrew Wolfson
Six weeks after she buried her husband — beloved retired judge Dan Schneider — Joann Schneider found a letter in her mailbox signed only "concerned citizen."
"I
am writing you because there is some information that was not shared
with you in regards to the death of your husband," the letter began.
The
writer told Joann Schneider that her husband was supposed to have
received an antibiotic every day after he was transferred to Masonic
Homes of Kentucky from a hospital on March 22, 2013, to recover from a
hip infection. He didn't get a single dose.
"Mr. Schneider never received any antibiotic medication," the writer said.
And
there was more. The writer said the home’s director of nursing and
assistant director of nursing both "knew this but failed to report it to
the proper authorities. It is not acceptable that this information was
withheld from the family."
At first, Joann
Schneider thought the whistleblower’s note was some kind of cruel joke,
said Josh Schneider, one of her two sons.
"As we later learned, it was all true and far worse than we could have imagined," he said.
The
nursing home company agreed to the payment on the eve of trial, the day
after a judge overruled its motion to keep the letter from the jury.
Med Care, a pharmacy supplier, agreed to pay an additional $1.9 million
to Joann, Josh and Jed Schneider.
A spokeswoman for Masonic Homes said after the accord was announced that Schneider’s maltreatment was "an isolated incident."
But
federal investigators found half a dozen violations that put residents
"in immediate jeopardy to health and safety," including medication
errors involving Schneider and multiple residents that were "likely to
cause serious injury, harm, impairment or death."
The
Centers for Medicare and Medicaid fined Masonic Homes $635,600, the
largest amount in Kentucky in 2013, a penalty reduced to $413,000 when
the facility waived its right to appeal.
'Cover-up' hid a host of problems
Records from that investigation and the lawsuit depict a frightening series of medication transcription errors by nurses, supervisors who failed to catch them, and managers who refused to report them, as the law requires, to the government and Schneider’s family.
The records show:
- Thirteen nurses wrote in Schneider’s chart that he was getting intravenous antibiotics daily, even though he never got a single dose.
- Ten days after her husband's admission, Joann Schneider asked during a care meeting how he was getting the antibiotic, having never seen him with an IV line. A note in a summary of the meeting mentioned the need to check on his antibiotic. No one did.
- When Dan Schneider was about to be transferred to Norton Suburban Hospital after 24 days at the Masonic Homes because his health had declined so dramatically — and a nurse finally realized the antibiotics error — the director of nursing, Michelle Lee, instructed that the information should not be shared with the hospital. Lee later said she wanted to complete an internal investigation first, to confirm the mistake had been made.
Responding to questions from the Courier Journal, the Masonic Homes' attorney, Darryl Durham, acknowledged in an email that "we did make some mistakes" and that "such errors in a health care setting can, at times, have serious consequences."
He said officials did not
report the mistakes to the state because there was a "difference of
opinion" on whether that was required, though now "we acknowledge it
should have been reported."
And Durham said it was
an isolated event in the context of "the thousands of medications that
are administered on a daily basis at a nursing center like Masonic
Homes," which has facilities in Shelbyville and Northern Kentucky as
well as Louisville.
But Chad Gardner, who
represented the Schneider family, described it as a "sad, scary case" —
especially given "how close they came to getting away with it."
He
said the errors likely never would have been discovered if not for the
whistleblower, who presumably was a Masonic Homes employee. Gardner
confirmed it was a woman but declined to identify her or say if she
still works at Masonic Homes, or if she ever did.
Durham said the nursing home doesn’t know who she was.
Misinterpreted orders cause chain reaction
Medical errors are not uncommon.
Safety
experts at Johns Hopkins have calculated that medical mistakes cause
more than 250,000 deaths each year in the United States. The Office of
the National Coordinator for Health Information Technology estimates
that nearly one in 10 people who check their records online
request corrections for errors.
Dan Schneider, who
retired in 1997 after 20 years as a district and circuit judge, then
founded a mediation service from which he’d also retired, was admitted
to Norton Brownsboro Hospital in March 2013 with a hip infection that
had spread to his bloodstream.
The hospital treated him for two weeks before transferring him to Masonic Homes' $40 million Sam Swope Care Center for rehab.
His
doctor ordered that he continue to get a daily dose of the antibiotic
Cefazolin for 28 days, as well as hemodialysis — HD for short — for
acute renal failure.
Nurse Bonnie Sue Baker, who
had already done seven admissions that night, stayed late to start to
process Schneider's paperwork, the records show.
Concerned
that the dialysis might wash away the antibiotics, she changed the
doctor’s order to add that Schneider receive the antibiotic daily "after
HD on HD days."
But nurse Teresa Bruner, who
finished the admission because Baker had to go home, interpreted the
order to mean the antibiotic should only be given on the days when
Schneider was to receive dialysis, which was three days a week, records
show.
Neither nurse called the doctor to verify the
prescription, as required, because they didn't want to wake him at 2
a.m., records show.
Compounding the error, floor
nurses in the Swope Care Center, believing that Schneider was getting
the antibiotic at the dialysis center elsewhere on Masonic Homes'
82-acre campus, charted that he was getting it every day.
And
a Med Care consulting pharmacist who was supposed to check Masonic
Home’s records to ensure residents got the correct medicine in the
correct dosage and frequency admitted she did not do so, records show.
After
a few days, Schneider's physical and mental condition began to fail.
When he suffered a fall, Masonic Homes decided to send him to Norton
Suburban on April 15, 2013.
That's when a charge
nurse discovered Schneider hadn’t received any antibiotics. The
assistant director of nursing asked Lee, the nursing director, whether
to disclose that information to emergency room doctors at Norton
Suburban.
Lee said not to, according to court records. "She wanted to complete the investigation," the assistant said later.
The
assistant director called the hospital anyway and said Schneider "might
not" have gotten the antibiotics. She acknowledged later it was a
"severely watered down" report.
Risky surgery fails to save the patient
Nobody told any of this to Joann Schneider.
She
found out her husband been moved to Suburban only from a phone message
that Masonic Homes left on her home answering machine, records show.
By the time she was able to transfer Dan Schneider back to Norton Brownsboro, said Gardner, "He was a very sick man."
Schneider
needed surgery to remove his infected artificial hip. Without it, he
would die. But his condition was so precarious that the surgery might
kill him.
Schneider underwent surgery and two days later, on May 2, 2013, he was dead, of sepsis and shock.
After
his funeral, Joann Schneider went to Masonic Homes on Frankfort Avenue
to retrieve her husband's belongings and to thank the staff for his
care. She had no idea what had happened there.
Then, in mid-June, she got the letter.
"Mr. Schneider was a very nice man who loved and cared about his family very much," it began.
"I
apologize in advance because I know that this information" will be
"upsetting to you, but it is not acceptable that this information was
withheld from you and your family. I pray that God gives you peace and
comfort during this difficult time."
'He loved his wife, his kids, his dogs and his sports cars'
Schneider
had long worried about suffering a premature death; he retired from the
bench at age 52, the year after his brother died at only 54 of a heart
attack.
"You can’t help but think about your mortality," he said at the time.
Originally
on the district court, he was one of the first local judges to crack
down on drunken driving. When he retired, from family court, fellow
judges praised his common sense, amiability and sense of humanity.
“He
was a kind, gentle man on the bench and at home," Gardner said. "He
loved his wife, his kids, his dogs and his sports cars — in that order.”
He
said Joann Schneider’s biggest loss was his love and companionship.
They met when he was 16 and she was 14, and they were high school
sweethearts.
They stayed together until the day he died.
“Dan and Joann Schneider’s life story,” Gardner said, “was a love story.”
In
court papers, Gardner said Masonic Homes botched Schneider’s care
because of staff cuts designed to improve its bottom line. He said in an
interview that nearly every employee who was deposed said staffing was a
problem and had told management so.
"They begged to add staff," he said.
Durham
said in an email that the facility complied with federal nurse staffing
rules and that Masonic Homes' staffing was "superior to virtually any
other home and still is."
In a memo before the
trial, he conceded there was "negligence on the part of a few nurses"
but maintained that there was no "gross negligence" that would warrant
punitive damages.
Masonic Homes said the medication error would have been caught if Med Care, which was sued by both sides, "had done its job."
Durham
also wrote that Schneider's death after surgery had "nothing to do with
the absence of antibiotic therapy" and said the failure to provide
antibiotics only hastened the need to remove his artificial hip.
Series of medication errors plagued facility
But federal and state investigators found that Masonic Homes made mistakes in giving — or failing to give — medication to at least six other patients and that other nurses changed doctors’ orders without approval.
According
to the Centers for Medicare and Medicaid findings, a resident with
dementia went six months without receiving medication ordered for gout. A
resident with end-stage respiratory disease got double doses of Lasix
because the order had been entered into his record twice.
A
third patient didn’t receive a prescription for melatonin for four
days, and when the error was discovered, nobody investigated why it
occurred. An executive director for Masonic Homes admitted its error
rate was "not acceptable."
Masonic Homes fired the
two nurses who admitted Schneider. Durham said it retained an outside
consultant to address its medication errors, then hired the consultant
as director of nursing and ultimately adopted a new electronic medical
record system.
He said its staff members are
"compassionate caregivers" and that Masonic Homes has a five-star rating
from the federal Centers for Medicare and Medicaid Services, a
designation held by less than 10% of nursing homes in the country.
Masonic Homes had five stars in 2013.
But Gardner
said that given the victim came from a sophisticated, well-educated
family, “it makes me shudder to think what happens to less educated
families in more vulnerable positions.”
Schneider is buried in a family cemetery in northern Wisconsin.
Josh
Schneider, a lawyer and former prosecutor, said the family is “forever
grateful to the writer of the letter. It took a lot of guts to do that."
"It
meant everything to our family that even in his last horrific weeks
somebody cared enough about Dad to break the code of silence at the
Masonic Homes to ensure that this never happened again to someone else's
loved one."
Gardner, whose co-counsel was Jake
Grey, also recognized "every other person formerly employed at Masonic
Homes and was willing to raise their right hands and tell the truth
about what really happened. It took a lot of courage for them to put
their careers and nursing licenses on the line.”
More about medication errors
An estimated 800,000 preventable medication-related injuries occur annually in nursing homes across the United States, according to Annals of Long-Term Care, a professional journal.
Another
study of 36 hospitals and skilled nursing facilities found that nearly
one in five doses administered were in error. Thirty percent of mistakes
involved failing to give the patient medicine that was ordered.
Errors occur most commonly when patients are moved in a nursing home or into another unit at the same facility.
At
any point in time, about 1.5 million people live in 16,000 nursing
homes across the country. Those patients are particularly vulnerable to
medication errors because they usually have multiple chronic medical
conditions, are functionally impaired, lack economic resources and
family caregivers, have cognitive deficits, and are taking large numbers
of medications, according to the U.S. Agency for Healthcare Research
and Quality.
Kaiser Health News in November identified the following examples of medication errors:
- A hospital pathology report identifying cancer that failed to reach the patient’s neurosurgeon.
- A patient whose record incorrectly identified her as having an underactive, rather than overactive, thyroid, potentially subjecting her to harmful medicine.
- A patient who discovered pages of someone else’s medical records tucked in her father’s records.
Kaiser
said in addition to incorrect information, omitting information on
medications, allergies and lab results from a patient’s records can be
dangerous.
What is — and was — the Masonic Homes?
Founded
in 1867, in part to care for Civil War victims, the Masonic Widows’ and
Orphans’ Home and Infirmary was the first and largest home built by
Masons in North America.
Originally
on Second Street in downtown Louisville, it provided housing, meals,
clothing and health care to children orphaned by Masons through death or
poverty. Widows could stay until death; children usually moved on when
they turned 18.
At
its peak, the orphanage had 600 children with 16 teachers for
kindergarten through high school. Students who wanted to go on to
college or trade school had their tuition paid by the Masons.
In
1927, Masonic Homes moved to a new campus on Frankfort Avenue worth $29
million in current dollars that featured eight two-story buildings that
served as dormitories and other buildings for the school, infirmary,
dining room, kitchen laundry and industrial workshop.
Students made their shoes and clothes and worked in the garden. The last orphan left in 1989.
Now
known as the Masonic Homes of Kentucky — there are facilities in
Shelbyville and Northern Kentucky — the nonprofit serves Masons and
non-Masons alike.
In
2010, it opened its $40 million Sam Swope Care Center, endowed by the
auto dealer, a lifelong Mason. It offers long- and short-term care,
advanced memory care and palliative care. Other units on campus offer
assisted and independent living.
Full Article & Source:
The 'sad, scary case' of how a nursing home whistleblower exposed a fatal cover-up
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