Home > Uncategorized > Dying, intellectually disabled man sent home twice from hospital

Dying, intellectually disabled man sent home twice from hospital

The disabled are often treated as second-class citizens, even in hospitals, says Dorothy O’Rourke.

O’Rourke is concerned that may have been the case with a resident of a state-operated group home in Chelmsford.  The 51-year-old man, whose name is being withheld, died earlier this month after having been taken twice in two days to Lowell General Hospital and sent away each time, apparently without any significant treatment. 

The man had been having difficulty breathing and was sweating profusely when he was taken to the hospital on both February 6 and 7.  He died, apparently en route to the hospital, after the group home staff called an ambulance for the third time on the afternoon of February 7.

The cause of death is listed on the death certificate on file in the City of Lowell as acute respiratory failure and aspiration pneumonia, which can indicate choking.  A death report form filed with the Disabled Persons Protection Commission, however, states that the man died after experiencing cardiac arrest.

Despite the possible discrepancy in the stated causes of death, the Chief Medical Examiner’s Office declined to do an autopsy, and the man’s remains were cremated.  He had lived in the same group home as O’Rourke’s son.

O’Rourke strongly defends the staff of the group home, which is managed by Northeast Residential Services, a division of the Department of Developmental Services.  “The staff there are wonderful,” she maintains. “They did all they could for him, including performing CPR.  It’s the hospital that kept sending him home.  I thought they would have at least kept and monitored him. I don’t understand it.”

O’Rourke has no information about what actually happened in the hospital after the man was taken there on each occasion.  But she maintains that many hospitals are ill equipped to deal with intellectually disabled people, particularly those who are non-verbal, as this man was.  “I think hospitals tend to ignore the mentally disabled,” she said. “I think they may need a special unit to handle mentally disabled people.”

A spokeswoman for Lowell General said the hospital would have no comment on the case due to privacy issues.

According to sources, the man had been sent to his day program in Lowell on the morning of February 6, and the staff at the day program made the first call to 911 to take him to the hospital.  A Lowell Police Department official said a squad car was sent to the day program site at 8:30 a.m. in response to a call about a male having trouble breathing.  (A police car was dispatched in addition to an ambulance each time, and the man was accompanied by a staff member to the hospital each time.)

The hospital released the man shortly after his arrival, however, and sent him back home.  The following morning, the man reportedly looked exhausted and “out of sorts,” and the group home staff made a decision not to send him to his day program that day.  By about 8 a.m.,  the man was slumped over in his wheelchair and sweating heavily, a source said.  A group home staff member called 911 shortly afterward.  A Chelmsford Police official said a squad car was dispatched to the residence at 8:30 a.m. 

However, once again, the hospital made a decision to send the man back to his home.  The DPPC report form on the death states that the man had been observed at the hospital on the morning of February 7 to be sweating profusely, but his vital signs were good when he arrived.  According to the report form, the man was sent home with a prescription (the name of which was redacted).

By the time he was back at the group home, he was leaning over the side of his wheelchair and was “sweating terribly,”   a source said.   After the staff noticed the man’s lips turning blue, they immediately called 911 again.  A staff worker couldn’t find a pulse. 

The DPPC death report states that shortly after arriving back at the group home, the man began to vomit and then lost consciousness, and that the staff began mouth-to-mouth CPR until the paramedics arrived.  According to the Chelmsford Police Department, a squad car arrived at the house at 1:45 p.m.  The group home received a call from the hospital later that afternoon that the man had died.     

The man was formerly a resident of the Fernald Developmental Center.  His case is the third we have heard about in which a former developmental center resident in his 50s died suddenly at a state-operated group home managed by Northeast Residential Services.  In this case, however, there doesn’t seem to be any indication that the group home was in any way at fault.

“The staff did a tremendous job,” one source said, echoing O’Rourke’s assessment.  “They did exactly what they were trained to do.  “They jumped right in and did their best to save his life.”

“We hope the DPPC does a thorough investigation of this case,” said Colleen Lutkevich, Executive Director of COFAR, a statewide, family-supported nonprofit organization that advocates for persons with intellectual disabilities and their families and guardians.  “If indeed this hospital was at fault in failing to treat this man adequately, we need to find out why.  In particular, we need to know whether his disability played a role in the apparent lack of care he received.”

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  1. Anonymous
    February 27, 2012 at 7:38 pm

    If we are searching for the truth regarding developmental disabilities and the group home system, this is not the forum in which to do it.

    There are several issues with this story:
    1.) The information came from the MOTHER of another resident of the home. Not only is this inappropriate on the mothers’ part, it is hugely unethical for the anyone to print this information as fact.

    2.) What were the underlying health issues of this individual? Many of our individuals have many health problems. I am not saying the Lowell General has a right to turn them away, but it is not always as clear cut simple as an article such as this makes it seem.

    3.) Was there anyone at Lowell General advocating for the individual? Many agencies/vendors will only employ nurses on a CONSULTANT basis, so when an something like this happens, the staff are left to handle it. Nurses advocate for patients everyday in all settings.

    It is situations such as this that make us realize the need to take a long hard look at the system. In some cases, no one is at fault. It is their time and God’s will. I would imagine his family and him were happy to get to live in the community for the time he did, I guarantee it was an improvement from an instituition.

    • February 27, 2012 at 9:03 pm

      In response to this comment from the anonymous reader, we confirmed all the facts in the blog post with sources and with the Chelmsford and Lowell police departments. The mother of the other resident provided us with some information and her opinion about hospital care in general for the intellectually disabled. All of her information was confirmed elsewhere and her opinion is clearly that — an opinion.

      Interesting that this reader feels the need to add a line denigrating insitutional care for the intellectually disabled. The post had nothing to do with institutional care. But as even the reader notes, many agencies/vendors will only employ nurses on a consultant basis. In that respect, it would have probably been better in this case had this resident been living in an institution, where nurses are full-time employees.

    • concerned
      February 27, 2012 at 10:44 pm

      The question to me is: Aren’t there nurses at this state operated group home? If so, why send this man to day program when he was clearly not well. The police were called to the day program at 8:30 am. This is neglect. If there is no staff nurse at the group home, there should be and that nurse should have gone to the hospital to advocate for this man who could not speak for himself. If there was no nurse at the group home, staff could have called NRS administrators and requested that a NRS nurse go to the hospital to advocate for the man. If that had happened, it might have prevented his death. If there is no nursing staff at the group home, there should be. These individuals are medically compromised and totally dependent on others for their care and advocacy. They need good nursing assessments. Group home staff are cannot be expected to provide the level of assessment that a nurse can provide nor should they. They don’t have the training.

      • Anonymous
        February 29, 2012 at 3:21 am

        Many group homes do not employ nurses on a full or part time basis, they employ nurses as either case managers or consultants.
        Direct Care staff are never asked to assess an individual, they can not, they do not have a license.
        Maybe the mother of the other resident could post a full health history and then we would know where to start to solve the problem.

  2. Anonymous
    February 28, 2012 at 1:42 am

    This is a very sad story. Many of us knew these 2 men. Now the guardians who left the “institutions” are learning what it’s like out there in the community. Too little too late. God bless their special soul’s.

  3. February 28, 2012 at 3:12 am

    Anonymous:
    This post was not about institutional care but since you brought it into the discussions, I don’t think you can imagine or assume that the family is glad this gentleman had the opportunity to live in the community for the time he did. I think it might be a fairer assumption that the only reason the individual moved to the community in the first place was because the family was forced to make a move because Fernald was closing.

    I’m not sure I agree with your assessment of the appropriateness of the information coming to light. The individual was not identified, only that this man passed away and there in conflicting information about the circumstances surrounding his passing. How can the system ever be corrected if problems are not identified?

    You are correct that there may be many underlying health issues involved here. But how did this man get to the state that he was in? I’m still trying to figure out why he went to his day program on the first day when by the time he got their the people at his day program had to call 911? Surely his condition couldn’t have deteriorated to that state during the trip. If it is as the death certificate states, apsiration pneumonia, that is very preventable.

    I’m not trying to bash anyone here, but there are a lot of questions that need to answered.

  4. Orzechowski Ed
    February 28, 2012 at 6:36 pm

    Several points:

    Yes, hospitals are often inadequately prepared to treat developmentally disabled patients, particularly when the patient is non-verbal. The presence of a guardian or staff from the patient’s residence to help communicate is crucial.

    Unfortunately, there is also a question of the hospital staff’s sensitivity and/or caring about such patients. Their attitude toward the developmentally disabled can extend from one end of the spectrum to the other.

    Tragic cases like this one are indicative of the need to maintain the availability of Intermediate Care Facilities that can monitor an individual’s health needs, an important safety net that is being lost to budget concerns. From all accounts here, the staff of the state-operated home did everything they could, but a temporary stay in an ICF might have averted this man’s death.

    Finally, the privacy issue. Certainly, privacy is important, but it is far too convenient and tiresome for agencies like hospitals or the Department of Developmental Services to cite privacy regulations when questions arise in situations like this one. Maybe the hospital staff did everything they could, as well. But how are we ever to be assured that nothing is being covered up under the guise of privacy?

    • concerned
      February 29, 2012 at 11:48 am

      Response to Ed: I agree with you that the state needs to maintain the availability of Intermedicate Care Facilities because of the excellent medical care they provide, but I strongly disagree with your statement that,” From all accounts here, the staff of the state-operated group home did everything they could.” Clearly, they did not and NRS management is to blame. Again, if proper nursing assessment had been done, this man would not have been sent to his Day Program. If there was no nurse at the house, staff could have called the Administrator on call and expressed concern for this man’s health or called 911 themselves. Instead, they wiped their hands of him by sending a desperately sick man off to his Day Program. If they were told to do that, shame of NRS management. If they did it on their own, shame on them. This man was desperately sick, because shortly after arrival the Day Program (which has nursing staff) immediately called 911 at 8:30 am.
      .
      NRS management knew about this man being taken by ambulance to the hospital. The Day Program had to notify them. NRS management should have sent a staff nurse to be with him, advocate for him.and demand the hospital admission this man needed. A good nurse would do that without question. Instead, this man was allowed to die because the people in charge of his care, did not care.

  5. Sally dyer
    February 29, 2012 at 2:52 am

    My brother was just rushed to Haywood Hospital and Gardner for Acute Colois and was extremely well cared for. The hospital staff are used to seeing a lot of patients from Templeton; now the care at Templeton that lead to this hosptialization is another story; not one I care to get into here. And yes, Templeton is closing in 2013 (confirmed), I need to find a safe place for my brother near/in Leominster if anyone has any recommendations, please let me know.

  6. February 29, 2012 at 1:03 pm

    I have to agree with concerned.

    Fernald residents are sent to Mount Auburn Hospital where they receive excellent care and attention. I can say with confidence, based on what we know, they would not have sent this man home with a prescription. I can also say that staff from Fernald would have accompanied him to the hospital to reassure him and advocate for him.

  7. Ruth Flynn
    April 17, 2012 at 11:24 pm

    In good consience they play the role they have been assigned but when confronted they vehemently deny wrong doing.

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