Case RESULTS

Ms. Benthin was one of the many victims of this RCFE’s corporate empire-building. On September 7, around 5:50 a.m., Facility staff knowingly left this 95-year-old vulnerable elder outside and unattended in the dark, despite their awareness that she was confused and disoriented, had a history of falls and exit seeking behavior, unsteady gait, was visually impaired, needed assistance of a walker to ambulate, and suffered from advanced dementia and osteoporosis.

Not surprisingly, Ms. Benthin suffered an unwitnessed fall, causing a gaping laceration to her right scalp and fractures to her frontal bone, right hip, right ribs, and right femur, along with multiple brain contusions with intracranial bleeding.

When she was later found by staff, Ms. Benthin was lying in a pool of her own blood. She was transported by ambulance to a local hospital. On September 10, after four days of extreme suffering, Geneva Benthin died from her injuries.

Through exhaustive investigation, we found that Ms. Benthin’s death was not the result of a few isolated mistakes by care-givers. Rather, it was the result of this corporate facility’s policies prioritizing occupancy and revenue while ignoring staff training, staff supervision, the number of staff on duty, and quality of care.

McNamara v. Confidential

“Where the Worry Ends” touts this Home Care Agency’s (“Agency”) website and marketing materials. Unbeknownst to prospective clients and their families, this Agency was willing to recruit scores of clients (such as Ms. McNamara), and leave them at the mercy of a revolving door of unqualified, unsupervised, and undertrained caregivers.

As the owner of the Agency was discovered to say, “Our biggest challenge is that we acquire clients before we have the caregivers.” Year-over-year turnover of their 200 hundred caregiver positions was a shocking 150 positions or 75%. Ms. McNamara, who was wheelchair-bound, incontinent of bowel and bladder, and had suffered from Multiple Sclerosis for more than 30 years, was assigned Caregiver(s) with no formal experience, no training on her Care Plan, and almost no supervision. Even had they been supervised, the caregiver’s Client Care Manager(s), were similarly undertrained, lacked meaningful experience, and gave instructions to caregivers that were not only incongruent but contradictory to Ms. McNamara’s care plan.

As a result of this Agency’s systemic issues, Ms. McNamara and her family’s worries were just beginning. After a critical two months where Kathleen was not bathed and multiple changes of condition went uncommunicated, unreported, and uncared for, on January 3, 2018, Kathleen was ambulance out to an Emergency Room, where her doctors and family were shocked to find that she had a stage IV sacral decubitus ulcer with a large area of gangrene down her thighs. Indeed, the large areas of skin loss exposed her anus, requiring a colostomy to be placed. Kathleen was then transferred to a hospital that specialized in wound care and then later to a skilled nursing facility. During hospitalization, she developed an infection to her wounds that almost killed her. Ms. McNamara will never regain her level of functioning she would have had if she had not been subjected to elder abuse.

Urman v. Vitas Hospice

In Jack Urman’s final months, he had two simple requests: 1) He did not want to die in a hospital—as his wife had; and 2) He did not want to die in pain- Jack was a Holocaust survivor, and for 6 years he endured torture, pain, starvation and indignities at the hands of the Nazis. In order to meet her dying father’s wishes, Jack’s daughter, Lynne, enlisted the services of VITAS Hospice to ensure he died with dignity.

Representatives of VITAS sold Lynne, and other families through its website, on its services by promising that on evenings and weekends they could call VITAS’s proprietary call center, “TeleCare”, to access nurses who would be available “right away” to aid in relieving patient’s pain. However, unbeknownst to Lynne or Jack, VITAS had no intention of dispatching its nurses “right away”. Indeed, VITAS’s own policies and procedures reflected that a “priority 1” visit, the most urgent calls for “pain…seizures…bleeding…fall with injury…severe caregiver distress, and some IV problems” - only required “that the dispatched VITAS staff be in route to the patient location within one hour of the [patient’s] call.”

Additionally, the requirement that a nurse be “dispatched” and “in route to the patient location within one hour” of a priority 1 call did not include the time it would take for the nurse to travel to the patient’s home. In VITAS’s Program 99, which covered Jack’s residence, on-call nurses were expected to visit patients within Placer County, Yolo County, Solano County, and Sacramento County, an area covering 4,429 square miles. In some instances, it took nurses an hour to drive from one visit to the next, and nurses traveled as much as 2,000 miles a month for visits.

A TeleCare employee who handled patient’s calls for VITAS, testified:

Q. And could you give me generally how many times you would hear those complaints from patients and families?

A. That we are not responding fast enough?

Q. Yeah.

A. Almost -- almost every day. Yeah.

On the weekend of October 5^th and 6^th, starting in the late evening of October 5^th, Jack was suffering from increasing abdominal pain and choking. During one of Lynne’s calls to TeleCare that evening, VITAS noted that Jack could be heard in the background retching. By the next evening, October 6^th, Lynne was pleading to VITAS to send a nurse to her home immediately.

At 6:16pm on the October 6^th, VITAS internal TeleCare notes indicated “send nurse on priority one”. By 7:42pm, more than an hour and half after Lynne’s initial call, a nurse still had not been dispatched to Lynne’s home, and Lynne called VITAS again. Lynne had spent the majority of the day watching her father suffer in agony from uncontrolled pain and muscle spasms, and heard her father’s moans and whispered pleas to “help me.” Lynne, desperate and in need of aide, told the VITAS representative during the 7:42pm call that she was going to call 911, despite VITAS repeated insistence that she only contact them.

At 8:05pm, Lynne was informed that the nearest nurse was 30-35 minutes away. Unable and unwilling to see her father in excruciating pain for another minute, Lynne called 911. Soon thereafter, an ambulance arrived and transported Jack to the hospital. At 8:37pm, two hours and twenty-one minutes after Lynne’s call that spurred a “priority one” nurse visit, a VITAS nurse arrived at Lynne’s home. Jack had already been transported by ambulance to the hospital. In order to relieve the intense and unrelenting pain and spasms, the hospital treated Jack with large doses of pain relievers and muscle relaxers. The medicine was so strong that Jack stopped breathing and passed away on October 8, 2012 at Kaiser Hospital. Lynne, because of VITAS’s recklessness, was devastated that she could not fulfill either of Jack’s dying wishes- he spent his last days alive in excruciating pain and died in the hospital.

Mr. Hammons was an Alzheimer's patient at a skilled nursing facility in Sacramento. As with many Alzheimer's patients, Mr. Hammons was easily confused and scared, and needed special care in many respects, including the administration of his medications.

Early in his residency at the facility, the facility contacted Mr. Hammons' daughter to inform her that her father was "being difficult" and had suffered a small skin tear on his arms as a result of the staff attempting to administer medication. Mr. Hammons' daughter informed the staff, although it is common knowledge in caring for residents with Alzheimer's, that it was imperative that they approach him gently and to explain to him what they were doing prior to simply grabbing him to administer the care.

She further instructed the facility that if they run into this problem again, they should immediately call her, day or night, so she could drive to the facility to assist. Two days later, Mr. Hammons' daughter received another call from the same staff member.

The employee stated that he had suffered another "minor skin tear" and that everything was fine. Feeling concerned, Mr. Hammons' daughter immediately went to the facility to check on her father and arrived to find her father with severe lacerations, and bruising, and injuries to his entire body, including his arms and face. Mr. Hammons' daughter immediately contacted 911 and her father was taken to Mercy San Juan.

Upon seeing Mr. Hammons' condition, the staff, without prompting, filed an abuse report with APS. Through our attorney's aggressive work, this matter was resolved early in the litigation process for a very substantial sum.

Mr. Flagg was a resident in an Alzheimer's unit of a skilled nursing facility. Another resident at the facility hit Mr. Flagg causing him to suffer a black eye.

Soon after this assault, the assaultive resident was inexplicably assigned to be Mr. Flagg's roommate. Later that month, Mr. Flagg was laying in his bed in his room. A Certified Nursing Assistant walked by his room and noticed his roommate strangling him.

This assault caused Mr. Flagg to have an acute change in condition, leading to his inability to eat, drink, or receive care, which ultimately led to his death days later. The facility concealed the true nature and circumstances surrounding Mr. Flagg's death, concealing from the Flagg family that Mr. Flagg had been strangled and telling the Flagg family that Mr. Flagg's death was a "normal" course of aging.

Having done an intensive pre-litigation investigation which was presented in very early mediation, the facility settled for a substantial sum.

Mr. Everhart, like the numerous other residents at the same facility, was a victim waiting to happen. While eating dinner at the facility, Mr. Everhart was confronted by another resident, Mr. A, who punched a very vulnerable Mr. Everhart, resulting in Mr. Everhart's death.

Mr. A had been a resident at the facility for five months, and over the course of those five months had engaged in numerous altercations with other residents, including two altercations which occurred in the 24 hour period before he assaulted and killed Mr. Everhart.

Prior to his admission at the facility, Mr. A had been twice admitted to a locked psychiatric ward for assaultive behavior. Through discovery, we found that no measures were taken to protect other residents from Mr. A. and that Mr. A was left, for the most part, unattended and unchecked by the staff. Realizing their failure to protect Mr. Everhart, a series of disturbing acts took place almost immediately after his death. The police were not called. Mr. Everhart was immediately moved by staff to his room, thoroughly cleaned, and shipped to the mortuary.

Only after a doctor refused to sign the death certificate were the Police and Coroner notified. Through litigation, Mr. Newman found that there had been over 200 incidents of resident to resident altercations in the year prior to Mr. Everhart's death. As a result of some of these incidents, residents suffered broken ribs, skin tears, and hematomas.

Most of the 200 incidents were never reported to state agencies. Mr. Newman also found Police had been out to the facility numerous times, and DPS had cited the facility twice in the previous year for failure to protect residents from resident to resident abuse. While the lawsuit could not bring Mr. Everhart back, it did spurn major changes in the facility and resulted in a substantial monetary settlement.