Cursory death inquiry leads to family’s quest for answers

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Another officer told Austin the police report would document the incident in case “this resident’s family was to come in and try do something … so it doesn’t become a big thing as to why it wasn’t documented.”

Eighteen days later, the resident, Ronald West, died of complications from a head injury suffered in the scuffle. An autopsy would later classify his death as a homicide, a determination that West died because of the actions of another person.

While that doesn't necessarily mean he was the victim of a crime, nearly two years after the Feb. 22, 2018, episode, the West family remains on an odyssey to find independent answers about what happened to their father in the upscale facility's dining room that day. The actions of the Provident Village leadership, Smyrna police and state regulators with the Department of Community Health have undermined those efforts. The case was reopened earlier this month after the AJC raised questions. But key evidence was never collected at the time of the episode, making it more difficult now to verify what happened.

The case is emblematic of problems families across Georgia face after breakdowns in care at assisted living communities or large personal care homes, an AJC investigation found. Police can be quick to accept the story of caregivers when incidents involve dementia patients and miss signs of potential elder abuse or neglect because of a lack of training. Regulators, who are short-staffed, also can fail to conduct thorough and timely reviews.

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In the Provident case, that left the West family largely on its own to seek answers.

Their cause has been complicated by an arbitration agreement the family signed when they moved their father into the facility in July 2017, waiving their right to sue. West’s son, Jobe, said the family had been in a crisis for more than a year trying to find help for his dad as his dementia worsened. So when Provident Village, a new facility that offered special memory care services, said it could take him, Jobe West said he thought their worries were over. Amid a stack of paperwork presented to him, he said he unwittingly signed the arbitration agreement. The family is now fighting the agreement in court.

“He had plenty of life to live and to share, and it was taken from him,” said Jobe West. “And that’s probably the most difficult thing to truly comprehend. Somebody basically took his life, and I’m here now trying to get somebody to admit their part in what has taken place.”

Provident Resources Group, the Baton Rouge, Louisiana, company that operates the facility, declined to comment about specifics of what it called an “unfortunate incident.” Provident Chairman and CEO Steve Hicks noted pending litigation restricts what he can say. He said the company followed the law and self-reported the incident to state regulators and police. Austin, Provident’s former director, didn’t respond to a request for comment. DCH also declined to comment.

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Ronald West had spent his life working and saving from his career in the construction business in Maryland. He had started with a shovel in hand and worked his way up to running a large construction company. He had moved to his retirement cabin in Whitesburg, Georgia, in 2014 to be closer to Jobe, the youngest of his three children, then to Provident Village to be closer to his son’s office.

Up to the time of the incident, Jobe West said, his father’s care at the facility had been good. And the facility staff seemed to like him. Though his father had Alzheimer’s, he was relatively active.

His background in construction led West to want to help the Provident Village maintenance staff, and he would sometimes assist with older residents who were more feeble. Just a week before the incident, Jobe West said, he and his sister had a wonderful visit with their father where he was laughing and cutting up. Jobe West said he’d never received a complaint from the facility about his dad.

So when Austin, the executive director, called to say his father had been in an accident and was in the hospital, he said he had no reason to be suspicious. When West arrived at the hospital, his father had bandages on his head and elbow and struggled to explain what had happened.

“My father couldn’t remember a whole bunch about it,” West said. “He complained about his elbow and his head and was wondering why it was bleeding and bandaged.”

But West later learned that Austin withheld some key details that day.

Son not given ‘full story’

Emergency call records show Austin phoned 911 the morning after the incident and reported that a caregiver and a resident had fought. When Smyrna’s uniformed officers arrived about 12 minutes later, Austin told them she didn’t know if what happened was a crime but expressed a need to report it.

She described how around 4:45 p.m. the previous day, Ronald West had become agitated in the dining hall as a 24-year-old male caregiver, Monte Bowser, tried to get him to move to a different chair. Ronald West, she said, punched Bowser across the right jaw, and Bowser reacted by immediately pushing the elderly man back. During that exchange, she said, West fell into a wall, causing the gash that required an emergency room visit and four stitches.

Credit: Fulton County Sheriff's Office

Credit: Fulton County Sheriff's Office

After listening to her story for less than two minutes, police told Austin that West wouldn’t be charged because of his dementia and Bowser wouldn’t face charges because he acted in self-defense.

Austin also acknowledged to officers that she hadn’t told Jobe West the “full story” about what happened to his father and that she had scheduled a meeting later that morning to explain.

“Last night, we just let him know, ‘Your dad had a fall, and we’re sending him to the hospital,’” Austin said.

She met with Jobe West about an hour after she told the story to police, and West said she gave him a similar account.

Hours later, Austin spoke with state regulators at the Department of Community Health, and the facility created a one-page incident report. It said that the facility had conducted a thorough internal review and fired the employee.

Though the facility told police that Bowser was acting in self-defense, Bowser’s separation notice said he was fired for “violation of policies — Disorderly Conduct & Violence-Free Workplace.”

Days later, state regulators closed the case without ever visiting the facility, noting that their review of the facility’s report “revealed that appropriate actions were taken.”

There’s no indication that DCH tried to determine if Bowser had been trained in how to recognize and handle agitation in residents with dementia. DCH apparently didn’t inquire, either, about whether the dining area was appropriately staffed at the time of the incident, or whether there were improvements the home should make to prevent future incidents.

» READ INSTALLMENT 1: A beloved father, a night of betrayal

» DEEPER FINDINGS: 20 deaths linked to violations at Georgia senior care homes

In fact, there’s no public record at all of the 2018 incident on the agency’s regulatory website. The AJC learned of DCH’s limited review only by obtaining some internal documents through a state open records request.

Meanwhile, West’s health declined rapidly. He picked at the staples in his head, and he suffered an infection. He was readmitted to the hospital, and his organs started to fail. He was placed in hospice care. His family was in shock when he died 19 days after the initial incident, less than a month after their last regular family visit when Ronald West was laughing with his adult children.

“It was a hard pill to swallow,” Jobe West said.

Nagged by skepticism about the facility’s story, he asked that the Cobb County Medical Examiner conduct an autopsy. When the results came back several months later, the word homicide stung him. His father died, the medical examiner ruled, of complications from the head injuries he suffered during the altercation.

Smyrna detectives revisited the case several weeks after the incident when the Medical Examiner’s Office contacted them during its review. A detective met with Austin, who said there was a witness to the incident: an employee who said that West attacked Bowser.

There’s no indication in the police report that officers followed up with the witness to corroborate the story. There’s no record that detectives interviewed Bowser.

The more Jobe West learned about the way the investigation was handled, the more he came to distrust the accounts he’d been told.

“You feel like, obviously you’ve been misled or lied to, and then you start finding out information,” West said. “So I just need the truth. I need to understand what happened, why it happened.”

Police apologize to son

Today, police investigators acknowledge mistakes were made.

Smyrna police reopened the case earlier this month after the AJC’s inquiry. Police now believe that Bowser may have been the only employee in the room at the time of the incident. An employee in a nearby room heard the commotion but may not have witnessed the scuffle. Police said last week they have interviewed Bowser, but that Austin, the former director, had not responded to their recent efforts to reach her.

Smyrna Chief David Lee has ordered a policy change to ensure cases involving seniors and senior care facilities receive a comprehensive review. The agency has also apologized to Jobe West for its handling of the case last year.

The department is committed to ensuring these cases don’t fall through the cracks, said Sgt. Louis Defense, a department spokesman. “It’s the mission of our agency to never shortchange our citizens,” he said.

The Cobb District Attorney’s Office also opened a review of the case this month after the AJC’s questions. “We are committed to protecting our elder and disabled citizens, and we appreciate the case being brought to our attention,” said Jason Marbutt, a senior assistant district attorney who specializes in elder abuse cases.

Even if the review raises more questions about Bowser’s actions, it may be too late to hold him accountable.

» READ INSTALLMENT 2: Suffering behind the facade

» READ INSTALLMENT 3: Prosecutors not alerted to potential crimes

After getting fired at Provident Village, Bowser went to work at Dunwoody Health and Rehabilitation Center, a nursing home in Sandy Springs.

The new job didn’t go well.

A dispute with another employee led to violence in July. The co-worker told Sandy Springs police Bowser cursed and threw a protein drink on him, then physically assaulted him.

Bowser acknowledged to police that he attacked his co-worker in a dispute over work assignments, records show. Both employees were fired, and Bowser faces a misdemeanor charge of battery with substantial physical harm in Fulton County court. Yet his Georgia certified nurse aide license is still in good standing, according to a state registry website. Bowser declined to comment for this story.

A spokeswoman with the rehab facility told the AJC it didn’t know about the incident involving Bowser’s termination at Provident Village.

This and the other disturbing information Jobe West has learned since his father’s death have left him doubting Georgia’s entire oversight system.

He hopes a court hearing next month will lead to the arbitration agreement being voided so he can pursue his lawsuit against Bowser and Provident. He said his legal fight has never been about money but about getting at the truth.

“I have a sense of responsibility to ensure that this doesn’t happen to another family,” he said. “That you don’t put your loved one in a facility that you think everything is being taken care of, that you think everything is just perfect. Then you get the call that there’s been an accident and come to find out it wasn’t an accident. It was something that should have been prevented.”