Families struggle for answers in senior care investigations

Clarissa Strickland holds her sister Nan Durrett's ashes at her home in Lilburn on Aug. 27. Her sister died in April of suspected COVID-19 after a stay in an assisted living facility. Strickland is still waiting to hold a funeral for her sister because her family has been scattered by the coronavirus. The family thought the state could have done more to alert them to citations regulators issued to the home related to Durrett's case. (Hyosub Shin / Hyosub.Shin@ajc.com)

Credit: HYOSUB SHIN / AJC

Credit: HYOSUB SHIN / AJC

Since her sister died in early April, Clarissa Strickland has wrestled with feelings of guilt and anger at how the final weeks at a metro-area assisted living facility played out. Nan Durrett’s health deteriorated steadily in late March after the home went on lockdown because of the pandemic.

By the time Durrett made it to a hospital on April 7, she had suffered several falls, dropped 11 pounds and lost the ability to feed herself. Over the course of the next 24 hours, her condition declined rapidly as she struggled to breathe. Doctors later told Strickland that her sister was presumed to have coronavirus, even though an initial quick-test during admissions came up negative.

She died April 8 before the hospital could complete a retest.

“The sight of her dying alone as I watched on FaceTime, writhing and moaning in pain, is something I will never be able to erase from my mind,” Strickland said.

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That nightmare and the belief that The Phoenix at Tucker assisted living home had failed their family led Strickland and her daughter, Courtenay, to file a complaint on April 27 with the state agency that licenses and oversees nursing homes, assisted living homes and other senior care facilities.

After months of waiting, the family received a letter from the Department of Community Health (DCH) in August that left them with more questions than answers.

The case is emblematic of the difficulties families can face when something goes wrong in a senior care home in Georgia and they feel they aren’t getting straight answers. While DCH talks and meets regularly with the industry it regulates, it has a reputation for being less than forthcoming with affected family members and the general public.

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DCH’s letter to the Stricklands offered little detail about the agency’s investigation other than to say it was completed and “the evidence obtained during the investigation was able to support one or more of your allegations.”

The letter failed to mention that regulators had sent an investigation summary report to the facility with specific violations outlined. DCH also didn’t say anything about a public report that was available online or that there were additional public records on the case available in the agency’s files.

The Stricklands didn’t learn about the availability of these reports until after they contacted a reporter at The Atlanta Journal-Constitution about the investigation’s conclusion.

“The lack of follow-up with us makes it feel like we are bystanders in this, rather than key players,” said Courtenay Strickland. “Families are and should be the primary stakeholders in this, and the process should be oriented accordingly.”

Melanie McNeil, Georgia's long-term care ombudsman, says, ”when families feel they are in the dark and residents feel they are in the dark, they get really frustrated.”

Over the years, said State Long-Term Care Ombudsman Melanie McNeil, her office has received complaints from families about the difficulty of getting information about a case, even after DCH has investigated.

”When families feel they are in the dark and residents feel they are in the dark, they get really frustrated,” said McNeil, the consumer advocate for senior care residents.

Those challenges have been compounded during the coronavirus pandemic. Families and even McNeil’s ombudsman representatives have not been able to visit facilities since regular visitations ended in March.

“The lack of follow-up with us makes it feel like we are bystanders in this, rather than key players.”

- Courtenay Strickland, whose aunt's death at an assisted living home is under investigation

DCH’s report on the Stricklands’ complaint found that the assisted living community had provided inadequate care. Durrett, who had Parkinson’s disease, Lewy Body dementia and a history of falls, fell at least five times in the two months she lived at the home.

State regulators also cited the facility for failing to respond to a disease outbreak.

Roswell-based Phoenix Senior Living, which operates the Tucker facility, said it was aware of the findings and has reviewed the DCH report in detail. The company also said it has been vigilant throughout the pandemic.

“We remain unwavering in our commitment to protect our residents and employees during this unprecedented time,” said Yolanda Doley Hunter, Phoenix’s vice president of risk management.

The facility said Durrett never tested positive for coronavirus while at the home.

Her family contends the home never tested her, even though they asked in March if she needed to be tested because she was running a fever and had other symptoms.

Mother went downhill after fall

DCH Commissioner Frank Berry and his agency’s leadership have declined repeated interview requests for more than a year to discuss the agency’s work regulating Georgia’s senior care industry. The agency will only respond to questions in writing.

The agency did not directly answer the AJC’s questions about why regulators don’t send copies of investigative reports to family members or at least alert them about the availability of reports online, even in cases where their loved ones have been harmed.

“DCH can mail inspection reports to the complainant upon their request; for quicker access, all interested persons can visit the GaMap2Care site,” the agency told the AJC.

DCH does send its investigation reports to the facilities, which the agency said is a requirement so that the they can correct any problems found.

Rep. Sharon Cooper, R-Marietta, said it’s common sense that a family member who filed a complaint against a facility would want to see the report once DCH finishes its investigation. (Ben Gray for the Atlanta Journal-Constitution)

Rep. Sharon Cooper, R-Marietta, said it’s common sense that a family member who filed a complaint against a facility would want to see the report once DCH finishes its investigation.

“They could be a lot more specific about being transparent to these families,” said Cooper, who chairs the House Health and Human Services Committee.

After the AJC interviewed her, Cooper contacted DCH leaders.

She said she received assurances that the department is in the process of tweaking the information it provides to families after its investigations to make it easier for them to find the reports online.

“Why not be more specific?” Cooper said. “That would be true transparency.”

Such a change could help people like Cheryl Andrews get answers.

Frances Smith, right, died April 30, 2020, weeks after she fell at a personal care home near Macon. Her daughter, Cheryl Andrews, left, blames poor care at the home for her mother's decline. (Family photo)

Credit: Courtesy: Cheryl Andrews, family Photo

Credit: Courtesy: Cheryl Andrews, family Photo

She filed a complaint with DCH in March after her mother received what Andrews considered was subpar care at a personal care home near Macon.

Andrews said her mother, Frances Smith, suffered for two weeks with an undiagnosed broken left hip after a fall at the home. After the fall, the 89-year-old, who had dementia, stopped walking and developed bedsores.

“My mother went downhill from there,” Andrews said.

Smith died April 30 as she was trying to recover at a rehab nursing home.

Months passed, but Andrews said she received no word from the state about its investigation. She contacted DCH in late August and they notified her the investigation had closed in April. A DCH regional director told Andrews via email that they had substantiated some of her allegations.

The supervisor said Andrews would have to file a public records request to find out details of the investigation. Andrews said she was told she may have to pay to receive the report.

The state said nothing about an investigation report that was posted online months ago that provides details of what regulators found as they cited the home for inadequate care.

The home’s administrator didn’t care to comment about Smith’s case, but said the home has updated policies and training to address any issues that occurred.

Andrews said she wants someone to be held accountable for what happened to her mother, and she’s troubled by the way the state handled the case.

“It really makes me feel like my mother was not valued because of the process,” Andrews said.