Nursing Home Blamed For Patient Death

BY MICHAEL L. OWENS
and DANA WACHTER
BRISTOL HERALD COURIER/11 CONNECTS
BRISTOL, Tenn. – Ninety-eight-year-old Anne Brightwell died in a hospice bed June 16, family members said, after months of screaming over a fractured left femur that would not heal.
Her upper leg bone shattered Feb. 6, when a hammock sling, used by Cambridge House nursing home staff to hoist her from a bed to a wheelchair, snapped. A medical examiner listed the broken femur as the cause of death on Brightwell’s death certificate.
Daughter Ruth Countiss said the fall could have been prevented, and accuses the nursing home of regularly using aging and tattered slings, but throwing newer equipment into use only when Tennessee Health Department inspectors arrived.
Three former Cambridge House employees say administrators hid daily-use equipment from inspectors, only to later pull it out after tucking away the newer items until the next state visit.
On Monday, Countiss filed a $2 million personal injury lawsuit in Bristol, Tenn. General Sessions Court arguing that Cambridge House “knowingly, intentionally and recklessly placed the safety of its residents .... in harm’s way to save money.”

Admittance and Discharge
Cambridge House administrators would not answer questions when Bristol Herald Courier and 11 Connects reporters visited the Bellebrook Road nursing home Thursday. Cambridge House is owned by AltaCare Corp., based in Alpharetta, Ga.
A letter faxed to the newspaper later that day by Cambridge House confirmed “an incident involving use of clinical equipment, resulting in an injury that was treated in accordance with accepted clinical standards of practice.”
The fax also stated that a hospital initially treated the patient, and that she returned to Cambridge House, where she stayed for several months.
“At the time of the resident’s discharge from the Cambridge House the injury was resolved,” the fax concluded.
Brightwell eventually left the nursing home for Bristol Regional Medical Center and then Wellmont Hospice House, where she died following a bout with pneumonia, said Countiss’ lawyer, Bristol, Tenn.-based Parke Morris.
“You’re looking at a ... woman with no health problems whatsoever until this happened,” Morris said in a July interview. “She hadn’t been to the hospital for 30 years before this.”
Granddaughter Amy Shell noted in an interview that Brightwell lived through her twilight years without ever needing prescriptions for such common elderly ailments as high blood pressure or cholesterol.
“Her cholesterol was lower than mine,” Shell said.
Brightwell landed in a Cambridge House bed late last October, to rehabilitate an ankle she fractured at her Bristol, Tenn., home, where she lived alone, except for nightly visits from relatives.
At Cambridge House, months of physical therapy flew by until she finally was able to stand without help for a full five minutes. Although a discharge day was never set, Shell said Brightwell likely would have left the nursing home by late February.
Expectations changed the day the hammock sling snapped, with Brightwell awkwardly slamming to the floor on her left side.
Because of her age, the bone would not heal on its own, Morris said. And, at her age, surgery to amputate the leg might have killed her.
The only option left for the aging matriarch was to rely on pain pills. Family members said it didn’t offer much help.
“Mom would lay in bed and say ‘Help me please, help me God, Jesus,’ and this would go on for hours,” Countiss said.

Equipment and Inspections

Former nursing aide Dickie Norris recalled in a Thursday interview the threadbare condition of the three hammock swings used at Cambridge House from last year until soon after Brightwell’s fall.
“They were frail ... like a worn out pair of jeans,” said Norris, who joined the nursing home in June 2008 and left in March.
Former nursing aide Brian Gross, who worked at the nursing home from May 2008 until October 2008, did not trust the slings.
“In those slings, I wouldn’t want to be lifted in it, and I weigh only 140 pounds,” he said.
Gross estimated that many of the nursing home’s patients weigh more than 200 pounds.
Brightwell weighed roughly 180 pounds, according to Shell, her granddaughter.
The lifts remained in use until four weeks after Brightwell’s fall. Norris said he was lifting a patient out of bed and had him in midair when an administrator appeared and told him to get the patient down and hand over the sling.
“Then they ordered slings, but they wouldn’t work on the (pulley) machines,” Norris said. “We couldn’t get people up for physical therapy for weeks.”
The hammock slings might have been discarded months earlier, had state inspectors seen them. Past nursing home employees said the Cambridge House administration went so far as to hide shabby equipment during health department inspections.
Former nursing aide Tony Apple, in a sworn deposition provided by lawyer Parke Morris, said that administrators pulled out newer equipment specifically for annual state inspections.
“Once the state inspection was over, the old slings came out,” Apple said in the deposition.
Apple’s statements are used in Countiss’ lawsuit.
“The defendant knowingly allowed frayed, dangerous slings to remain in use rather than spend the money to properly supply the facility with safe, non-frayed, hammock transfer slings,” the lawsuit states.
Gross recalled that the slings shown at inspection were slightly used, but in much better shape than the ones kept in daily circulation.
Not only were the hammock slings in ill shape, said Shawna Caudill, a former Cambridge House nursing manager, but the bedsheets, towels and other linens showed considerable wear, too.
Caudill, who joined Cambridge House in April 2007 and left in November 2008, said the administration purposely overlooked the shabby quality of equipment.
“The faulty equipment was definitely brought up at many meetings, but it all boiled down to cost,” Caudill said.
One administrator’s “exact words were to put on my big-girl panties and deal with it.”