18 Felony Counts Of Abuse And Neglect In Nursing Home

michigan.gov, Apr 26, 2006

LANSING – Attorney General Mike Cox announced today that he has charged eight individuals from Metron Nursing Facility of Big Rapids with a total of 18 felony counts in connection with the death of 50-year old female resident Sarah Comer of Big Rapids on January 16, 2005

 “This tragic death simply shouldn’t have occurred,” said Cox. “Families should not have to fear that medical negligence could take the life of their loved one. My office will continue to be relentless in pursuing those who put the lives of Michigan’s citizens at risk.”

Charges were filed against five Registered Nurses, the Medical Director/Mecosta County Deputy Medical Examiner, the former Nursing Home Administrator (N.H.A.) and a Certified Nursing Assistant (C.N.A.) at Metron. The charges include: involuntary manslaughter, accessory after the fact as a result of a cover-up, falsification of medical records, tampering with evidence and five misdemeanor charges, including failure to report the incident to the Department of Community Health (D.C.H.), following the asphyxiation death of Ms. Comer.

Cox alleges in the complaints that a 50-year-old female Medicaid recipient was transferred, for rehabilitation purposes, from Spectrum Health in Grand Rapids to Metron of Big Rapids in the late afternoon on Saturday, January 15, 2005. The new resident was extremely oxygen-dependent as she had been weaned from a ventilator to oxygen just 48-hours prior to her transfer. Oxygen-dependent residents at Metron of Big Rapids are supplied with portable K-tank oxygen cylinders. The resident required a very high concentration of oxygen (15 liters/minute) and could only survive a few minutes without oxygen assistance.

There was a vacant room on NE Hall where the staff was experienced in caring for more compromised patients and where oxygen usage records were kept. Instead, the resident was placed in a room at the far end of NW Hall, also known as the Medicaid Hall, where staff did not normally care for oxygen-dependent residents and where no oxygen records were kept. No special instructions or orders were given to staff to monitor the oxygen levels or track the tank depletion between 11:00 p.m. and 7:00 a.m. Assigned staff was limited to 2 C.N.A.s, one of whom was assigned to a particular resident from 10:30 p.m. until 3:00 a.m., and one nurse supervising both the NW and NE Halls.

Cox further alleges that the oxygen tank was never changed and ran out before 6:45 a.m. Early morning reports to nursing staff that the resident was experiencing dizziness were ignored. Facility records indicated that the victim was found dead at 8:50 a.m. Medical examiner investigators looked into the incident but were not informed that the resident's oxygen tank was empty. The medical records indicate the same. As a result, no autopsy was performed and the death certificate was instead sent to the resident's former physician for signature with the cause of death incorrectly listed as myocardial infarction due to natural causes.

 Metron of Big Rapids administration, assisted by staff, falsified medical records to conceal the resident's condition and status to cover up the asphyxiation death. Further, staff completed a written report to D.C.H., omitting any reference to the oxygen tank depletion and also any internal investigation and subsequent results. Vital information was also withheld from investigators from D.C.H.

 One of the charges also relates to the facility's failure to report that Dorothy Pearl Johnson, of McBain, another 64-year-old female oxygen-dependant resident on NE Hall, died the same day at 9:00 a.m. The cause of death was listed as Chronic Obstructive Pulmonary Disease. The resident had complained of shortness of breath days before her death.