FORT WORTH -- Evan Fleming lay motionless, not breathing, at a nursing home as nurses and other medical personnel tried to make up their minds about whether to try reviving the 23-year-old.
Seven minutes passed before staff at DFW Nursing & Rehab began chest compressions, according to state records.
A nurse practitioner at the home later told investigators after Fleming's September death, "A seven-minute delay is never OK."
CPR within the first five minutes is crucial, according to medical experts.
The Texas Department of Aging and Disability Services said DFW Nursing's "neglect" of Fleming and the home's policies and procedures -- seven nurses lacked current CPR certification -- posed an immediate jeopardy to Fleming and potentially dozens more, according to an investigation report obtained by the Star-Telegram.
"Why are they still open? That's what I want to know," said Fleming's mother, Tracey Fleming. "Why ... are these bastards still open? They don't have any more business running a facility than my cat does."
DFW Nursing's administrator did not return repeated phone calls, and the home declined to release a public report about the incident.
What was the DFW Nursing staff doing during those seven minutes? They were combing through Fleming's medical records, trying to determine whether the young Fort Worth man had a "do not resuscitate" order because the facility's own records were unreliable and not used, state officials found.
A state inspection also found that 43 other residents were in a serious or immediate threat "situation" because of flaws in the facility's system of identifying patients who were to be resuscitated.
For instance, a few days after Fleming's death, investigators walked through the halls of the nursing home and found that six rooms had stickers indicating whether patients should be given life-saving measures or left to fate.
Of the six, four were labeled incorrectly.
A likable college student and waiter, Fleming lived with his mother in a Fort Worth apartment. In August he was in a single-car accident in which he lost control and slammed into a metal pole. He suffered traumatic head injuries and broken bones.
After surgery at a local hospital, the young man, who had a tracheotomy, was moved to DFW Nursing for rehabilitation but had not yet awoken. Fleming's father said he was told that an autopsy revealed that some swelling in his son's brain may have cut off impulses to breathe.
The Tarrant County medical examiner's office listed the cause of death as trauma due to the car accident.
Fleming died Sept. 14, a week after arriving at DFW.
The Star-Telegram acquired the state inspection report from the Texas Department of Aging and Disability Services and has filed a complaint against the home with state officials for not providing documents.
The report indicates how inspectors believe that Fleming was neglected and how his quality of care was deficient:
At 9:25 a.m., a nurse aide called a nurse to Fleming's room because he was not breathing and had no heartbeat. It wasn't until 9:32 a.m. that a floor nurse started CPR.
Between those times, medical personnel at DFW Nursing frantically tried to determine what to do. A licensed vocational nurse hollered down the hall to attract the attention of a registered nurse and confirmed that Fleming was supposed to be revived. A nurse aide called 911.
At 9:41 that morning, paramedics arrived and took over CPR before Fleming was pronounced dead at 10:03 a.m.
The facility was ill-equipped and ill-prepared to deal with such an event, the state found. In addition to the nurses' lack of CPR certification, the home's emergency policy indicated that a blood pressure cuff and stethoscope should be on a crash cart. Yet a few days after Fleming's death, state inspectors found that the cart was missing the blood pressure cuff, the stethoscope and functioning batteries for a flashlight.
A nurse practitioner later told state inspectors that "whatever happens with this incident, there needs to be some education on what is a [emergency medical] code and what isn't."
After Fleming's death, the facility was required to audit its directives for all of its then 63 residents, and each chart was flagged with either a green insert reading "FULL CODE" or a red insert reading "Do Not Resuscitate."
Residents were also given a wrist band bearing a red dot as another confirmation to not start life-saving measures, the state report says.
Arrangements were also made to obtain CPR certification for all licensed vocational nurses and changes were made to ensure at least one CPR-certified LVN on each shift.
Fleming's father said sympathy also seemed in short supply at the nursing home after his son's death.
"They should have at least offered an apology of some sort. An e-mail, a phone call or a letter," Charles Fleming said. "It's just like they swept it under the rug."
He said that the only condolences he got in writing were from the University of North Texas, where his son had been a student for a short time.
Darren Barbee, 817-390-7126