2 years after patient dies with high levels of drugs, family still unable to get answers

Jimmy Johnston spent a year in the hospital under Baker Act and guardianship

In January of 2022, the ABC Action News I-Team reported how Jimmy Johnston was involuntarily committed, placed in guardianship and spent more than a year in Morton Plant Hospital as his family fought to get him out. He died in the hospital, and a toxicology report showed high levels of drugs were in his system when he passed. Since then, I-Team investigator Adam Walser has been following his family’s ongoing search for answers and accountability.

By: Adam Walser

CLEARWATER, Fla. — In January of 2022, the ABC Action News I-Team reported how Jimmy Johnston was involuntarily committed, placed in guardianship and spent more than a year in Morton Plant Hospital as his family fought to get him out.

He died in the hospital, and a toxicology report showed high levels of drugs were in his system when he passed.

Since then, I-Team investigator Adam Walser has been following his family’s ongoing search for answers and accountability.

“You can imagine the sadness here”

“The first thing I did was call Clearwater police,” said Kathleen Johnston, writing with a marker on a poster board.

She documented the many twists and turns in her family’s search for answers about her brother Jimmy Johnston’s death.

“This is just a small sample of the papers and the hoops we’ve been going through to get some justice for Jimmy,” Kathleen said, pointing to files of documents related to contacts she had with local and state governments.

Jimmy, a U.S. Navy veteran who struggled with schizophrenia, died alone after spending a year in Morton Plant Hospital while his family fought in court for his release.

“You can imagine the sadness here of us having to do this,” Kathleen said.

Kathleen’s sister Patty and brother Tommy share in the sadness.

The siblings all live in Indiana and can’t sue the hospital because Jimmy didn’t have a wife or any children.

“That’s not the issue. The issue is, why did they do this to him?” said Tommy.

Kathleen has used her professional skills to try to come up with answers.

She is the founding director of an investigative journalism center at Indiana University.

“I was a senior investigative producer for CNN, I worked at CBS News, I worked in newspapers. I’ve had a long career in this business,” she said. “The system is not working.”

A year in the hospital under a Baker Act and guardianship

 Jimmy and his sisters signed a form at Morton Plant Hospital in January 2020 designating Kathleen and Patty, his healthcare surrogates, to make decisions if he couldn’t.

“They insisted that we sign it,” Patty Johnston said.

But when Jimmy returned to Morton Plant for a mental health episode three months later, the hospital went to court without contacting his family and had him involuntarily committed for six months under Florida’s Baker Act, saying “the patient requires a highly structured setting for safety and cannot be maintained safely outside of a hospital setting."

A lawyer working for the hospital then obtained guardianship without informing the judge that Jimmy’s sisters were his surrogates.

A guardian paid by the hospital was put in complete control of his care.

Kathleen hired a lawyer, went to court and was eventually appointed his guardian, but Jimmy's doctors refused to release him.

“I’ve helped people all my life in my career, and I couldn’t save my own little brother’s life. It’s gut-wrenching, it’s gut-wrenching,” Kathleen said.
 
Toxicology report shows high levels of drugs

Jimmy died on March 21, 2021, three days before a hearing to determine if his family could move him out. His death certificate listed natural causes.

But a toxicology report from a private autopsy his family paid for raised concerns about the level of drugs in his body.

“The cause of death of this gentleman is most probably a result of overdoses of medicine as obtained in the toxicology report,” Kathleen read from the private autopsy report.

Forensic psychiatrist Dr. Craig Beach reviewed the findings for the I-Team.

“The Clozapine level was around 20 times higher than the upper limit of that usual blood level range for Clozapine. And the Haloperidol level was around 50 times higher,” Beach said.

A hospital spokesperson said in an email, “While we cannot comment directly on any patient’s toxicology results, we do know that blood levels for some pharmaceuticals are significantly higher when drawn postmortem.”

“Those levels aren’t normal. There’s no way to pretend that they are,” Beach said.

“The only place he was getting the drugs was the hospital. They were administering it to him,” Tommy Johnston said.

Kathleen sent the autopsy and toxicology reports to multiple local and state agencies, but none followed up with the pathologist.
 
“Not the health department, not the prosecutor, not the police,” Kathleen said.

State agencies don’t provide answers

The Agency for Healthcare Administration, which oversees hospital safety in Florida, investigated 16 months after receiving the complaint and closed the case after a single visit.

“At the time of the inspection, they did not find the facility was violating any laws,” Kathleen read from a letter in which AHCA closed the case.

Kathleen filed complaints with the Florida Board of Medicine.

“They lost one of the complaints against one of the doctors,” Kathleen said.

Then there was another issue.

“They said the expert is unable to read the records because the hospital sent them over jumbled,” Kathleen said.

Jimmy had more than 24,000 medical records at the time of his death.

A hospital spokesperson denies that there was a problem with how they were turned over to the board, saying in a statement, “The hospital turned over a single digital file with records in chronological order.”

In a closed meeting, a committee heard the case and found the doctors did not violate standards of care.

“It’s closed door. I can’t be in there,” Kathleen said.

“Somebody needs to be accountable”

A Clearwater Police spokesperson told us the investigator Kathleen spoke with had died, and they couldn’t locate records on the case.

Kathleen sent all the records she had to Assistant State’s Attorney Rene Bauer, including autopsy report, the toxicology report and a 1,500 page abstract she obtained from the hospital after a legal battle.

“She said I’ve decided with the evidence I have, there’s not a crime here,” Kathleen said.

Bauer told the I-Team she thoroughly reviewed the documents, but there was not enough evidence to prove to a jury that a crime had been committed and who was responsible.

Jimmy’s siblings said they’re not giving up.

“Somebody needs to be accountable,” Tommy said.

We contacted the Florida Board of Medicine and AHCA about their investigations but did not receive any additional information.

The family has also contacted federal agencies, who they say are looking into different aspects of the case.

They contacted Indiana Sen. Mike Braun's office and he brought Jimmy's story to the floor of a U.S. Senate committee hearing about problems with court-ordered guardianship earlier this year.

"I heard from the sister of Navy veteran Jimmy Johnston who said that a court ordered guardianship ultimately led to her brother’s death," Braun said.

"After Jimmy’s death, his family received a hospital bill of nearly $1.2 million. Nearly all of it was billed to Medicare. That’s unacceptable," he said.

If you have a story you think the I-Team should investigate, email  adam@abcactionnews.com

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2 years after patient dies with high levels of drugs, family still unable to get answers

Investigative report slams treatment at Falls rehab center

BUFFALO, N.Y. (WKBW) - A disability rights organization has released a scathing report, slamming patient treatment inside the Niagara Rehabilitation and Nursing Center.

In the 14-page report, investigators from Disability Rights New York note, they were contacted in November, 2016.  Complaints included poor care and dismal conditions inside the facility.

The facility has 160 beds.  The group made three visits to the facility and reviewed patient records, interviewed residents and staffers.

Disability Rights New York investigators say the facility was not clean or safely maintained.  They explain at least one patient was physically and verbally abused.  Additionally, investigators say the facility "failed to provide adequate meals and did not meet the nutrition needs of residents."

One resident, according to the report, said her bed sheets hadn't been changed in months.  She said she was living in constant pain because of a lack of medical care.

Investigators say they found many residents had the same bed sheets for several weeks.

"Residents complained of the urine stench in the halls," the report notes, because of dirty linen bins in the halls.

Some say they were treated inappropriately by staffers, who are accused of "kicking residents' beds to wake them."  During each visit, investigators say they found staffers did not respond to call bells.

 One resident even recorded other residents calling for help, but was forced to erase that recording.

A former resident said she was "forced to remain in her bed for days because staff was unwilling to transfer her to her wheelchair and were unresponsive to call bell requests..."

"During DRNY's visits to NRNC we were forced to maneuver around residents in wheelchairs who had been left in the middle or to the side of the hallways," the report explains. It goes on to say those residents were sleeping in wheelchairs. Some, investigators say, were "staring at the wall or ground without speaking or moving."

Investigators say they found dirty floors and walls.

The report notes residents were given meals that "do not meet their dietary needs..."  In fact, investigators say some residents weren't fed at all during some mealtimes.  (Continue Reading)

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Investigative report slams treatment at Falls rehab center

Family says North Las Vegas Care Center was nursing home nightmare

By Darcy Spears. CREATED May 8, 2015

Las Vegas, NV (KTNV) -- We count on them to care for us or for our loved ones.

Medical facilities where people go for rehabilitation and skilled nursing care.

But when the care isn't there, the consequences can be devastating.

Tonight, Contact 13 Chief Investigator Darcy Spears has one family's nursing home nightmare at a place with a history of problems.

"It's my mom.  It's my only mom.  I don't have another mom," Robert Purdy said, looking over old photos, including one of his mom, Joanna Lewis, seated next to Elvis Presley.

She was a beauty queen and a smoker most of her life.

"And it caught up to her, finally, after 60 years," said Purdy.

But he doesn't believe the smoking alone killed his mother.

He and family friends believe the North Las Vegas Care Center is partially to blame.

"They quickened the process of her dying," said family friend Marsh Masek.

"I think they just put a diaper on her and put her in a bed and that was it," added Joanna's best friend, Karen Davis.

In February, Joanna was having trouble breathing.

She went to a hospital and after several days was discharged to North Las Vegas Care Center.

Darcy Spears: She was supposed to get rehab and get released?
Robert Purdy: Yes.  And it just, uh, she got very, very poor care there.

Karen Davis says she repeatedly asked staff to make sure Joanna stayed hydrated.

"And I said please, please, somebody get on the ball and do something about this!"

Two weeks after being admitted, things went very wrong.

"I noticed that her wrists and her ankles were blue," said Robert.  "And I noticed that her urine was very dark.  And I asked the nurse--I said, what's going on?"

Joanna's North Las Vegas Care Center records document an "unplanned discharge" by ambulance to North Vista hospital on February 27.

There's nothing in the record about why 911 was called, except to note it was the resident's and family's request.

"I said, do not let my mother die!"

In his complaint to the state, Robert reports that his mother had to be placed on life support at the hospital.

He claims she had pneumonia, a urinary tract infection, low blood pressure and severe dehydration.

"They immediately had to give her two liters of fluids, which is a lot."

Even so, Joanna Lewis was never able to recover.

She died earlier this week, but you can still hear her voice on Robert's home video.

Just a few days before she passed, Robert and Karen recorded her thoughts about North Las Vegas Care Center.

Joanna: It was just a bad experience.

Karen: Do you feel like they did anything for you that helped you?

Joanna: No.

Robert: How many times did you push that buzzer without any response?

Joanna: A thousand times.

Contact 13 learned North Las Vegas Care Center was written up by the state in April, 2014 for call buttons being out of patients' reach.

Two months later, state investigators found call bells not operating and residents not being effectively monitored.

Contact 13 reviewed hundreds of pages of state records documenting problems at the North Las Vegas Care Center.

In the last three years, the facility has paid more than $38,000 in fines.

In 2014, violations include inadequate care resulting in bed sores, failing to properly investigate multiple abuse allegations and patient injuries, and exceeding the medication error rate allowed by the state.

Also, a resident's clothes caught on fire and his chest was burned because they violated their own policy by allowing unsupervised smoking.

The state is currently investigating Joanna's case.

"Nobody deserves to suffer," said Robert, breaking down in tears.  "It's just a horrible thing."

And it's not just over the last year.

In May, 2012, state records show patients with unexplained injuries, patients left without oxygen, and inaccurate, incomplete medical records for half the sampled residents.

"I want this to be a wake-up call," said Karen Davis.  "I don't want what happened to Joanna to be in vain."

No one from North Las Vegas Care Center would go on camera.  In a written statement, Administrator Michael Fleming said:

"Everyone at North Las Vegas Care Center values the trust our residents and their families place in us, and we take any concerns they may have very seriously.  Due to privacy rules and regulations we are not permitted to provide any details about an individual’s care.  However, it is our policy to conduct a comprehensive internal review upon learning of concerns from a resident or family member and we are committed to swift and appropriate action to resolve any issues that might keep us from meeting our residents’ needs. I can assure you that everyone at North Las Vegas Care Center remains committed to the care and safety of our residents."

In a second statement, he wrote:

"Obviously if Mr. Purdy chooses to discuss his mother on television he has every right to do so but we cannot participate as we feel it is inappropriate to discuss a patient’s care in a television interview. Furthermore, with respect to your inquiry regarding state surveys, healthcare facilities are routinely subject to surveys which can result in monetary fines to ensure the facility is in compliance with Medicare and Medicaid requirements. Federal and State surveys are just one way we can identify areas in which we can improve. 

The staff at North Las Vegas Care Center takes the input of outside regulators very seriously and we work diligently every day to meet  and exceed the standards placed on us.  We work closely with the appropriate agencies to make meaningful changes that benefit our residents and we are constantly striving for improvement.  We  continually undertake quality and satisfaction initiatives designed to produce positive outcomes for our residents."

Regulatory agencies often just write up violations and allow facilities to correct their mistakes.

You should always check a facility's history before you place a loved one.

The Nevada State Health Division's Healthcare Quality and Compliance section sent this statement:

"An important message for your viewers:  When considering placing a loved one in a facility that HCQC licenses, you can always request a copy (or copies for prior years) of the facility’s inspection reports.  We try to post the surveys/plans of corrections on our website, but as we transition to our new website, there may be delays in posting the surveys.  After a loved one is placed in a facility, family members/friends are always encouraged to visit during different times of the day/week, ask for a copy of the most recent inspection report, get to know the staff and feel free to ask questions. Also, anyone can file a complaint with HCQC, via telephone, email, snail mail, or in person.  Complainants can remain anonymous.

If you want to look up a licensed facility, you should be able to find them here and here.

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Family says North Las Vegas Care Center was nursing home nightmare