March 27, 2014

State investigating death in Fort Worth Alzheimer’s care facility

A police report indicates the 90-year-old woman told an employee that she felt she was having a heart attack but employees didn’t call 911 immediately.

State officials are looking into the death of a 90-year-old woman at a northwest Fort Worth residential care facility after concerns were raised that employees didn’t immediately seek medical help for the woman after she indicated that she was having a heart attack.

Police were called to the Avalon residential care facility at 4551 Boat Club Road at 2:21 a.m. Tuesday in reference to the death of 90-year-old Mary Madeline Edholm.

According to a police report, MedStar paramedic D. Hart told officers that he had arrived at the facility to find three employees standing around Edholm’s body.

The police report states that a female employee gave the following account to the paramedic, which he shared with police:

The employee said that she had gone to help Edholm after the woman had fallen, when Edholm informed her that she felt like she was having a heart attack.

The employee said that she got Edholm some water and placed her back in bed. She told the paramedic that she then sat with Edholm for about 10 minutes before Edholm became unresponsive. The employee then went to call her manager.

The employee “told Hart that she attempted to call her manager before calling MedStar because it was in their SOP’s (standard operating procedures) to call the manager first in case of any emergency,” the report states.

Hart told police Edholm was already showing signs of lividity — the pooling of blood in a body after death — when paramedics arrived.

“Due to MedStar’s observation of [Edholm] upon arrival and the unknown time lapse between [Edholm] telling employees she was having a heart attack and the 911 call being placed, it is believed that a significant amount of time had [passed] before employees made any attempt to contact emergency medical services,” the police report states.

Phil Edholm, Edholm’s son who lives out of state, declined to comment Thursday.

Not criminal, police say

According to the police report, officers interviewed the female employee at the scene, who confirmed she had been sitting with Edholm when the woman stated she was having a heart attack.

She told police that she had been sitting with Edholm for about 45 minutes when Edholm began to fall to the floor. She brought Edholm some water, then helped her to her bed. Two other employees also came into the room to assist her with Edholm.

After sitting with Edholm another 10 minutes, Edholm became unconscious. The employees attempted to check Edholm’s blood pressure but the machine kept showing an error. The employee could find no pulse on Edholm but said she was still breathing, according to the police report.

When Edholm began to turn blue around her mouth and her hands became cold, the employee and one of the other staff members went to call their manager while the third employee remained with Edholm.

Unable to get ahold of her manager after several attempts, the employee then called another staff member and “asked her what they needed to do” for Edholm, the police report states.

Only then, the report indicates, did the employee call 911.

Homicide Sgt. Joe Loughman said he contacted Adult Protective Services on Wednesday about the incident.

“I don’t see that it’s criminal,” Loughman said. “I see that it’s irresponsible care giving but did they willfully do anything to kill this person? No.”

Case referred to state agency

Shari Pullman, a spokeswoman with Adult Protective Services, confirmed Thursday that a report had been received by the agency and that is had been referred to the Texas Department of Aging and Disability Services (DADS), which investigates such matters.

A spokesman at Avalon’s headquarters in Dallas did not immediately return a message seeking comment Thursday.

Avalon’s website states residents are given continuous care by trained staff, as well as supervision and monitoring 24-hours a day for changes in “physical, mental, emotional and social functioning.” It also states the home gives continuous communication with family, physicians, and other appropriate persons or agencies regarding a resident’s needs.

The police report notes that there was not a working nurse at the facility, which is also known by the name The Willows Assisted Living community.

The facility is licensed by the state as a small/large Class B Assisted Living facility for those with Alzheimer’s or related disorders.

DADS records show no state standard violations were noted at the facility during inspections conducted for the purpose of investigating complaints and incidents in the past 12 months. The facility’s last comprehensive inspection was conducted Jan. 21 and revealed no violations.

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