A Fort Worth assisted living facility was neglectful when staff failed to immediately call 911 after a resident complained she was having a heart attack and later became unresponsive, according to a state investigation.
The Department of Aging and Disability Services (DADS) had begun investigating Avalon’s The Willows Assisted Living Community at 4551 Boat Club Road in late March following the death of 90-year-old Mary Madeline Edholm.
A MedStar paramedic told police that Edholm was already showing signs of lividity — the pooling of blood in a body after death — when paramedics arrived on the scene March 25.
Employees at the center, which cares for Alzheimer’s and dementia-related patients, told police they had attempted to take Edholm’s blood pressure after the woman became unresponsive but the machine kept reading “error.”
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They also told police that it was the facility’s policy that they first contact the manager in such an emergency before 911 was called. After repeated unsuccessful attempts were made to reach the manager, an employee told police she eventually got a hold of another supervisor who told her to call 911.
By then, according to some employees’ accounts, an estimated 20 minutes had passed since Edholm became unresponsive.
Homicide Sgt. Joe Loughman alerted Adult Protective Services about Edholm’s death, previously telling the Star-Telegram that while no crime appeared to have been committed, the incident appeared to him as “irresponsible care giving.”
According to a copy of the investigation report, received this week by the Star-Telegram, DADS investigators conducted an investigation inspection of the facility April 2 and found it did not meet state license requirements.
“We found conditions in the facility that presented an Immediate and Serious Threat to resident health and safety,” the agency wrote in an April 16 letter to The Willows.
Melissa Gale, a DADS spokeswoman, said Thursday that the state agency was still contemplating taking enforcement action against the facility. Actions that could be recommended by the agency include denial of payment for new admissions, administrative penalties, or loss of certification, she said.
Other agencies, including the Texas Attorney General’s Office, typically handle such enforcement, she said.
In all, DADS investigated 10 allegations against Willows. Five of those allegations were substantiated and led to citations:
• Investigators found that while there was insufficient evidence to say that Edholm died from a heart attack, evidence did reveal that Edholm had experienced a “life-threatening change of condition” and that staff failed to immediately call 911.
• The facility was neglectful in not maintaining a working blood pressure cuff.
• The facility was neglectful in not immediately calling 911 when another resident, who died Feb. 5, experienced a “life threatening change of condition.”
• The facility inappropriately kept another resident at the facility despite the person being permanently bed-fast, thus no longer meeting the requirements for such a facility.
• The facility failed to follow regulatory requirements and immediately report and investigate injuries and allegations of abuse or neglect of residents. The report states the facility reported Edholm’s death to the state only after a state investigator had questioned them on why the incident was not reported.
A plan of correction has since been put into place, including the retraining of employees to call 911 first in an emergency situation, replacing batteries in the blood pressure machine and purchasing a backup machine and performing annual checks and calibrations on the equipment. Staff will also be training on reporting requirements in the event of abuse, neglect or exploitation allegations, according to the report.
Tim Seib, Avalon’s direction of administration, declined to comment Thursday, citing the on-going investigation.
Phil Edholm, Mary Edholm’s son, said that when an employee called him in the middle of the night to inform him of mother’s passing, he was told that “they had checked my mother while she was sleeping and found that she was not breathing.”
“We know that’s contrary to the truth but that’s what I was told,” he said in a telephone interview Friday.