Report cites failures at Georgia veterans' home leading up to resident’s death

A patient at the Georgia Veterans War Home in Milledgeville never got the mental health evaluation he needed for his aggressive behavior this year before he allegedly beat another resident, who died moments later, according to a state inspection report obtained by The Atlanta Journal-Constitution. BOB ANDRES /BANDRES@AJC.COM

Credit: Bob Andres

Credit: Bob Andres

A troubled patient allegedly beat resident who died moments later

A patient at the Georgia Veterans War Home in Milledgeville never got the mental health evaluation he needed for his aggressive behavior this year before he allegedly beat another resident, who died moments later, according to a state inspection report obtained by The Atlanta Journal-Constitution.

The report cites a series of failures leading up to the violent confrontation on April 8. At one point, a physician’s assistant referred the troubled patient for an evaluation on March 24, but the outpatient veterans' clinic that could have helped him was closed at the time because of the coronavirus pandemic.

Meanwhile, COVID-19 has infected 181 patients and killed 42 at Georgia’s two nursing homes for veterans in Milledgeville and Augusta, state records show. At the Milledgeville location, 74 staff members have tested positive for the coronavirus disease.

Nationwide, tens of thousands of residents at veterans' homes and other long-term care facilities have died from the disease. Those deaths make up a substantial portion of the more than 217,000 Americans who have succumbed to COVID-19 so far.

Last month, for example, Massachusetts Attorney General Maura Healey announced two top officials at the Soldiers' Home in Holyoke had been indicted on criminal neglect charges for their roles in a COVID-19 outbreak that contributed to the deaths of at least 76 residents. In New Jersey, more than 140 residents and employees have died from COVID-19 at three veterans' memorial homes.

In Georgia, Department of Community Health officials inspected the Milledgeville nursing home in response to five complaints, three of which they substantiated. The inspectors found the nursing home failed to follow the agency’s rules for providing mental health services to one of its residents who demonstrated an increase in “aggressive behaviors.”

The report does not identify that resident. But a Milledgeville police report says a staff member at the nursing home witnessed David Tarpley on top of Roland Daigle and punching Daigle in the face. Tarpley, according to the police report, “stated that he told Daigle to get out of his room 3 or 4 times and he wasn’t listening to him so he ‘wacked him’ a couple of times. Tarpley also said they were standing up when he hit him and that he didn’t think he had hit him that hard.”

Moments later, Daigle fell to the floor and died, the state inspection report says. The altercation exacerbated Daigle’s heart disease, causing his death, according to the inspection report, which cites autopsy and death certificate records and calls his manner of death “homicide.”

Tarpley was admitted to the nursing home last year following a diagnosis of “dementia with behavioral disorder,” alcohol dependency and aphasia, the inability to understand or express speech.

The inspectors reviewed medical records from the nursing home that show Tarpley was causing trouble as far back as November, when he refused baths, had a short temper and became easily annoyed with other residents who wandered into his room. The following month, nurses observed him becoming annoyed when other residents got in his way. He fussed and cursed at them.

In February, he was “trash talking and verbally threatening staff.” In March, he cried and yelled when he talked about his military service, attempted to kick others, urinated in the dayroom, had a bowel movement in his trash can and refused attempts to monitor his vital signs. He was also seen cussing and kicking at another resident. The staff said he was possibly struggling with post-traumatic stress disorder.

A physician’s assistant at the nursing home said on March 11 he would refer Tarpley to a clinic for a mental evaluation, but that never happened, according to the inspection report. A referral was made later that month, when the clinic was closed because of the pandemic. The patient could have gotten help through telehealth, but that also never happened. At one point, Tarpley was referred to another health care provider but he was “not accepted due to lack of payment source.”

The AJC found no records of Tarpley being charged with any crimes in connection with Daigle’s death. Asked about the status of the case, Milledgeville police referred questions to the local district attorney’s office. Stephen Bradley, the district attorney for the Ocmulgee Judicial Circuit, declined to comment other than to say: “As with most cases, we consulted with the investigators soon after the death. Once we receive all the documentation, the matter will be reviewed to determine the next step.”

The Georgia Department of Veterans Services also declined to comment on the case, saying it remains under investigation. But the agency said both homes in Milledgeville and Augusta are fighting the spread of COVID-19 by limiting access to their buildings, checking the temperatures of visitors, requiring masks and regularly testing staff and patients for the disease.

“The pandemic brings new medical challenges every day and we are working directly with federal, state, and local government agencies and community partners to ensure we do everything we can to combat this disease,” Georgia Veterans Service Commissioner Mike Roby said in an email.

“Both facilities have taken all necessary infection control precautions in line with industry standards and guidelines from the Georgia Department of Public Health, the U.S. Department of Veterans Affairs, and the CDC.”

As of Wednesday, there were no COVID-19 cases at the Milledgeville location, though there was one patient with COVID-19 at the Augusta location, Roby added.

PruittHealth Veteran Services of Georgia, which operates the nursing home in Milledgeville through a contract with Roby’s agency, said it was “saddened by the event that resulted in the loss of a beloved veteran, and we offer our sincerest condolences to the veteran’s family and loved ones during this difficult time.”

“Our veterans' safety and well-being remain top priorities at PruittHealth,” the company said in an email. “We continue to work with authorities and state agencies on this matter, and cannot comment further.”

Daigle’s obituary says he served in the U.S. Navy Reserve during the Korean War and is survived by three children and six grandchildren. Born in Madawaska, Maine, he graduated from the University of Florida and worked in the insurance industry in Atlanta, later opening a real estate business. He died just a day before he would have turned 89.

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