The staff at a veterans’ live-in care center in Decatur knew the facility had an ant infestation problem for months before patient Joel Marrable was found covered in bites and later died.
Because the Department of Veterans Affairs failed to deal with the infestation, multiple veterans were bitten over three months and moved from room to room. Then Marrable’s daughter discovered her father in distress with ant bites September 6. Marrable, a terminal cancer patient, died a day later.
A copy of the VA’s investigation summary, obtained by The Atlanta Journal-Constitution, says the problems were caused and exacerbated by a pervasive lack of leadership and accountability, repeated internal communication failures, inappropriate staffing, failures by cleaning staff, lack of proper supervision, and a work culture that lacked a sense of urgency and failed to communicate with veterans’ families.
“It is confounding that something like an infestation of fire ants can go on unchecked and affect these precious people for such a long period of time without a successful or appropriate remedy,” said Josh Sacks, an attorney for Marrable’s family.
The VA released a statement saying, “The incident that occurred with our veteran, Mr. Marrable, in our Community Living Center, was unacceptable, and since September 2019, we have taken drastic steps to ensure it never happens again. … We concur with all the team’s recommendations in the recently released Administrative Investigation Board findings report. The appropriate disciplinary action was taken against all staff involved.”
It has established a permanent housekeeping staff, retrained workers and started new reporting procedures.
The VA finished the investigative summary December 4, but has not released a copy to The Atlanta Journal-Constitution, despite a request made under the Freedom of Information Act January 9. The newspaper received a copy from another source.
The summary says staff at the Eagle’s Nest Community Living Center noticed ants in rooms and beds as early as June 4, and that veterans were bitten numerous times in July and August. Environmental Services began spraying some rooms for ants in July, but were using the wrong pesticide.
Workers noticed Marrable had multiple ant bites and found him “covered with ants” September 2, and a staff member said ants were found in his room a month before, the summary says. Again, on September 5, ants were found in his room and he had bites. The family was not notified. His daughter, Laquna Ross, found out September 6 during a visit, saw the numerous bites and questioned the staff. Marrable died September 7. An autopsy was done, but the results are blacked out on the summary.
Sacks said experts he consulted with believe the bites hastened his death.
After Ross reported the incident, a regional administrator was put on leave and retired shortly afterward. The region's chief medical officer and seven other staff members were reassigned.
Sacks said the Marrable family hopes the report will mark a turning point so this will not happen to other veterans and families.
The 34 residents of the Eagle's Nest were recently moved to other locations in Georgia, Alabama and South Carolina to clear space in case of a surge of coronavirus cases.
ORIGINAL DOCUMENT: Read the VA report