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State veterans center where Sapulpa man died had multiple serious failings, investigation finds

Tulsa World - 3/19/2017

Investigators from the Oklahoma State Department of Health probing the choking death of a Sapulpa man found that the Oklahoma Veterans Center at Talihina "failed to provide sufficient staff" to protect his safety.

And the Oklahoma Department of Veterans Affairs now says that four employees of the state-run nursing home for veterans have been reported to their respective licensing boards for possible disciplinary action in the case.

Leonard Smith, 70, was an advanced dementia patient living in a locked-down, special-needs unit when he choked to death Jan. 31 after being given food, fluids and medication. After he died, a medical provider found that he had a plastic bag lodged deep in his throat.

In a just-released report from the state Health Department'sProtective Health Services, investigators said they found no documented history of the resident having swallowing difficulties or of swallowing foreign objects.

They determined that the Talihina veterans center:

Failed to "ensure a resident was free from neglect" by providing supervision and ensuring a safe environment when an unsupervised Smith picked up a knotted plastic trash bag another resident left on a table and swallowed it.

Failed to "thoroughly assess, monitor and intervene" following an incident involving two residents.

Failed to investigate low-level workers' reports of an incident in November in which Smith passed a portion of an examination glove in a bowel movement.

'No history of swallowing foreign objects'

Chris Cornwell, Smith's niece whom he had entrusted with his power of attorney, said she was pleased that the Health Department investigation vindicates her family.

"He had no history of swallowing foreign objects or chewing on foreign objects - he'd never done anything like that prior to being there, and even while he was there, we never received any type of notification that he had swallowed a latex glove," Cornwell said from her Sand Springs home. "The nurse practitioner, Kathy Davenport, when she called me when he passed away, indicated he had chewed on an IV tube and that's why he couldn't receive IV antibiotics anymore. That's still not in any report."

The chairman of the governor-appointed Veterans Commission, tasked with oversight of state veterans centers, made a public statement a few weeks after Smith's death implying Smith's family had failed to properly warn ODVA about his habits when he was admitted at Talihina.

Chairman John Carter said ODVA staffers told him that Smith "had a long history of ingestions of things perhaps that were not edible and this was not passed on to admissions when he was admitted."

Smith served as a radar technician in the U.S. Navy for five years during the Vietnam War, earning the Vietnam Service and Vietnam Campaign medals. He had been a resident of the Talihina veterans center, about 150 miles southeast of Tulsa, since January 2014.

ODVA operates seven veterans centers that provide intermediate to skilled nursing care for veterans. The centers, which are funded by a combination of federal and state dollars, are in Ardmore, Claremore, Clinton, Lawton, Norman, Sulphur and Talihina.

The state Health Department report indicates that three investigators were dispatched to Talihina in the wake of Smith's Jan. 31 death - for five days between Feb. 6-13.

Long-term-care facilities found to be out of compliance with state or federal rules and regulations must submit a plan of correction.

The Talihina center has already submitted its corrective action plan to the state Health Department, which included those details in the investigative report.

They include the removal of all trash cans and trash bags from certain areas of the nursing home; new requirements for the safe storage of trash bags, gloves and wipes and safe display of decorations; discontinued use of Styrofoam cups; and regular checks for such hazards in the special-needs unit.

ODVA Deputy Director Doug Elliott told the World that also as a result of Smith's death, two licensed practical nurses "were reported to their nursing board by the facility" and a nurse practitioner and site administrator "were submitted to their licensure board by the Central Office."

State Sen. Frank Simpson, R-Ardmore, who has said Smith's life was "senselessly lost" said he, too, had received a copy of the Health Department's investigation.

He said the report has been provided for review by the local district attorney. And he said although criminal accountability for Smith's death may not be possible, the very existence of such a public report about an ODVA nursing home's failings is still noteworthy.

"Five years ago, you would not have this report you have now," Simpson said. "In 2003, ODVA administration leveraged legislation that exempted veterans homes from Health Department oversight. In 2013, we brought the veterans centers back under their inspection."

He said the state Health Department's findings in Smith's death further bolster his newly proposed legislation to close the Talihina veterans center and relocate it to a new facility in a bigger city in the same part of the state, possibly Poteau.

Labor pool too small

Simpson said the employee pool in the Talihina area is far too limited to keep up with the increased demands of replacing staff who have left Talihina - and the number of vacancies has grown so high that the center is in jeopardy of having the U.S. Department of Veterans Affairs cut its number of allowed patient beds.

"The thing that jumped out at me first from the investigative report was that the facility failed to provide sufficient staff. Turnover is a problem I've been aware of at all ODVA centers for six or seven years, but it is significantly higher at Talihina," Simpson said. "My concern is if we don't start moving soon, we are going to go into a death spiral where we lose beds. We are not too far away from having to close down 30 to 50 beds because of staffing."

Simpson said another unique issue is contributing to staffing troubles at Talihina, but he thinks ODVA's central administration is "between a rock and a hard place" in how to address it.

"Many employees are hesitant to report things because of the close relationships of the people in charge at that center. It caused me very serious concern. Do these relationships shield people from accountability?" Simpson said. "I spoke with one RN who had only worked there for a short period of time because she was afraid she would lose her license. But I'm not sure what they could do - we don't have anyone to replace them with. That's the challenge we have."

Officials at the Oklahoma Medical Examiner's Office said their report about the exact cause and manner of Smith's death is still pending the results of toxicology tests.

The man's surviving family members have received his cremated remains but are waiting for a planned visit this summer from Leonard Smith's brother, who lives out of state, to lay him to rest at Fort Gibson National Cemetery.

 
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