Neglected: Could review teams prevent deaths of elderly patients by Florida nursing homes?

Teams of professionals reviewing the deaths of the elderly when abuse or neglect is suspected would help protect Florida's seniors in nursing homes, advocates argue.

“I think in every major urban area, it’s absolutely essential that they have an elder death review team in place,” said Paul Greenwood, a former prosecutor in San Diego who headed one of the nation’s largest elder crimes units. He now educates police officers and prosecutors nationwide on pursuing such cases.

Greenwood and others argue such review teams would help reduce the practices identified by a USA TODAY NETWORK - FLORIDA investigation into the state's nursing homes. In 54 deaths where neglect and mistreatment were identified by another state agency from 2013 through 2017, Florida's Agency for Health Care Administration rarely took action and in some cases didn't investigate the deaths, the Network investigation found.

The Network’s series on nursing homes also showed how AHCA rarely takes serious actions against poor-performing nursing homes, and how it has allowed dozens of nursing homes to limp along for years, providing substandard care, and abusing, neglecting and even killing patients with little consequence.

When a child dies in Florida and there’s even a hint of possible abuse or neglect, a team of professionals tries to find out if and how the death could have been prevented.

It’s been that way for nearly 20 years, after the Florida Legislature established the Child Abuse Death Review Committee in 1999, with the goal of reducing child deaths in the state. Ten years later the state established domestic violence death review teams in response to an increase in domestic violence-related homicides in Florida.

Paul Greenwood
(Photo: San Diego County District Attorney's Office)

But there is no comparable review when an elderly or vulnerable adult dies in Florida, even under suspicious circumstances.

Proposed legislation to establish elder death review teams has failed to pass the Legislature the last two years.

Review teams, Greenwood said, could help determine if nursing home patients’ deaths were preventable or if there are lessons to learn that could prevent another patient’s death.

San Diego County established a death review team more than 15 years ago. The team included, among others, prosecutors, police, a medical examiner, health care administrators and adult protective services investigators.

Lessons learned

Greenwood reviewed several of the cases included in the Network’s investigation and said each would have benefited from a follow-up review. He called the 2017 death of York Spratling at Consulate Health Care of Jacksonville “the classic case that needs to be submitted to an elder death review team.”

York Spratling(Photo: Family photo)

Spratling, 84, died after surgery to remove dead tissue from his rotting genitals, which became infected when he wasn’t regularly bathed at the nursing home. The nursing home’s staff didn’t alert a doctor about the wounds or severe infection for five days, a review by Florida's Department of Children and Families found.

Spratling’s death was due to inadequate supervision and medical neglect, according to the review by DCF,which investigates elder abuse and neglect. However, AHCA took no action against the nursing home, and no criminal charges were filed in the death.

“This is where we would say, 'No. 1, was this death preventable?' And I think the answer is, 'Yes,' ” Greenwood said. “ ‘No. 2, what lessons can we learn from it?’ And one of the lessons we can learn just from looking at this case is the lack of exchange of information between relevant authorities.”

Preventing death

The same year Florida created its committee to review child deaths, the U.S. Department of Justice recommended the development of death review teams for the elderly. But unlike child death review teams, which are in every state, only 13 states have established elder death review teams, according to The National Center for Fatality Review and Prevention in Washington, D.C.

Florida is not among them.

Bill Benson, senior policy adviser at the National Adult Protective Services Association in Washington, said one reason the nation hasn’t embraced elder death review teams is because children’s deaths are typically considered unusual. An elderly person's death, however, is usually not considered peculiar.

“What’s unusual about that?” Benson said. “And that becomes a way to cover up an awful lot of deaths that probably shouldn’t have happened.”

Bill Benson, national policy adviser
 for the National Adult Protective
 Services Association. 
(Photo: Contributed)

The goal of a death review team is not to place blame or force court action, although that can happen if it turns out the death was due to neglect or abuse, Benson said.

The primary reason for review teams is to learn from deaths and discern ways they could have been prevented. That could lead to policy changes, new regulations or updated procedures, Benson said.

“It’s a dual purpose, prevention and then correcting the behavior that took place,” he said.

The Women's Center of Jacksonville is in the planning stages of an elder fatality review team pilot project examining the closed criminal cases involving elder abuse, neglect or exploitation.

The goal would be to see if "a change in policy or procedures may be needed," said Community Education Director Eleen Rodden. "To see if there is something in the system that needs tweaking."

The team would not look at a nursing home case, however, where there was no criminal prosecution, even if there was a finding of neglect by Florida's Department of Children and Families, Rodden said. And the program is limited to Duval, Nassau and Baker counties. Rodden said she knew of nothing similar in other counties in Florida.

Working together

Death review teams improve investigations by bringing together people from a number of disciplines, said Teri Covington, director of the Washington, D.C.-based nonprofit Alliance for Strong Families and Communities.

The teams identify systems that are failing or can be improved, and they can identify risk factors in unnatural deaths that can lead to prevention efforts. It’s also possible a team could review a death and discover a perpetrator who intentionally caused it, Covington said.

The death review teams also provide data that can make the public aware of the problem. Because elder deaths are rarely reviewed and often assumed to be due to old age or a chronic condition, “you let people get away with murder,” she said.

Sen. Audrey Gibson, D-Jacksonville
(Photo: Carroll Gambrell)

State Sen. Audrey Gibson, D-Jacksonville, has pushed legislation to established elder death review teams in Florida’s 20 judicial circuits. Her efforts have failed over the last two legislative sessions, but she plans to file the proposal again.

Gibson said her goal for the statewide effort is to impact public policy, and to determine if state resources exist to prevent unnecessary elder deaths.

“As a policymaker, we’re not looking for fault,” Gibson said. “We’re looking for improvement in the quality of life in an elder, period.

“If something happened that negatively impacted the life of that elder, and there are things policywise we can do to prevent that moving forward, we have an obligation to do that.”

Rep. Barbara Watson, D-Miami Gardens, who has pushed unsuccessfully a companion bill in the state House, said her interest in the legislation stems from a personal experience.

Years ago, a friend’s father suddenly began to deteriorate at a Florida nursing home. He stopped eating and stopped speaking, and the nursing staff didn’t really seem to notice, she said.

“It wasn’t until his autopsy that they found that he had actually swallowed his dentures,” Watson said. “Why did the nursing staff miss his dentures? Why did they not even try to discover what was the issue?”

Rep. Barbara Watson, D-Miami Gardens
(Photo: State of Florida)

Under Gibson’s proposal, the review team's records on cases would not be public and would not be turned over for civil or criminal cases, although those same documents could be available from other sources. And although the team's work would be confidential and focused on recommendations for policy changes, nothing would prevent state agencies from acting on information gleaned from individual cases.

The cases must be closed either by the DCF or law enforcement before coming to the team for review, she said.

The idea of death review teams at times is opposed because of concerns over cost, even though most teams are volunteer efforts and require funding only for organizational and administrative costs, Benson, the Washington-based policy adviser,said.

Opposition to death review teams also comes from health care providers, nursing home owners, assisted living facilities and others in the health care industry, he said.

“I think there’s a lot of entrenched interests for whom it’s in their interest that we don’t dig too deep,” Benson said. “And that’s what elder death review teams do. They dig deep.”

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Neglected: Could review teams prevent deaths of elderly patients by Florida nursing homes?