WCAX Investigates: State probes nursing home after patient suffers mysterious injuries

Published: May. 4, 2021 at 5:33 PM EDT
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BURLINGTON, Vt. (WCAX) - A Vermont nursing home is under investigation after a patient suffered mysterious injuries. The probe at Elderwood comes on the heels of a series of compliance problems at the Burlington facility.

Families entrust long-term care facilities to provide compassionate care and to keep their loved ones safe. The unexplained injuries to a resident living there has one family doubting that trust.

“What happened to her should not have happened,” said Mary Pilon of St. Albans, who has a loved one at Elderwood.

Pilon says she wants to stop this from happening to anyone else.

The morning of April 24, Pilon Facetimed her mother and saw she was injured.

“It looked like she got punched in the eye,” Pilon said.

Sometime between Friday, April 23 and Saturday, April 24 Elderwood, Pilon’s loved one sustained a black eye, broken wrist and bruised head.

Pilon’s mother is declining with dementia, so she can’t recall the incident.

Pilon says nursing home staffers told her they don’t know how her mom was injured.

There are no surveillance cameras in patient rooms.

“They’re saying they found her that way,” Pilon said. “They said there’s no way that they can tell if she fell, but we think she fell.”

But Pilon says she doesn’t believe her mom could have fallen on her own. Pilon says she is so weak, she can hardly lift her arm above her head, let alone get in and out of bed.

“They can’t show me any proof. If you can show me proof that she fell, then OK, that’s what happened,” Pilon said.

Pilon says she’s not satisfied with Elderwood’s explanation.

“There’s nobody that picked her up, there’s nobody that saw her on the floor or anything. She was on the bed when they found her, and she was naked with just her Depends on,” Pilon said.

Reporter Christina Guessferd: What did you suspect may have happened?

Mary Pilon: Somebody must have abused her.

Pilon reported the incident to DAIL, the state Department of Disabilities, Aging and Independent Living’s Licensing and Protection Division. She says an investigation has been launched, not only into her loved one’s injuries but also into the facility’s practices.

That division encompasses two entities -- Adult Protective Services and Survey and Certification.

DAIL officials say they cannot share specifics of the investigation but they can speak broadly about cases of this kind.

“A phrase that we employ all the time is: when in doubt, report,” said Joe Nusbaum, the director of the Division of Licensing and Protection at DAIL.

Nusbaum says his office receives reports daily, culminating in more than 4,000 every year.

He says for a report to turn into an investigation, the complaint must meet two key criteria. First, a vulnerable adult must be identified. Second, the person filing the report must make a firm allegation of maltreatment, which includes abuse, neglect or exploitation. If his office can back both, that report is triaged either to Adult Protective Services or Survey and Certification, triggering an investigation. Policy requires it be completed within 120 days.

Nusbaum says about one-third of reports are investigated.

“It’s really a thorough, well-documented process of just exhausting everything that we can to get the best evidence that we can,” he said.

After doing more digging, WCAX News also learned Elderwood has been the subject of numerous complaints spanning as long ago as last August, prompting investigative visits from DAIL’s Survey and Certification division nearly every month since.

“I wouldn’t say it’s alarming, but I would say I am concerned,” said Suzanne Leavitt, the director of survey and certification at DAIL. “I’d like to know what’s going on in that facility.”

Investigators with Leavitt’s office visit health care facilities, often unannounced, to ensure compliance with both federal and state regulations.

If they are not in compliance, the office helps the site develop a plan to fix the problems.

They’ve now done that with Elderwood at least seven times, addressing reported issues with resident care from lack of hygiene maintenance to preventable medical conditions like pressure sores to unwitnessed falls resulting in significant injury and requiring hospital intervention.

“They do keep coming back under compliance, which is good,” Leavitt said. “But what I would love to see is a sustained process where we’re not having to go this often. That’s not what a successful system looks like.”

In fact, Survey and Certification says the issues rise to a level of “potential for harm” which is one step down from a citation of “actual harm.”

“We don’t want to see any harm. We don’t want to even see minimal harm, but we’re still at the point where we are not seeing significant harm here,” Leavitt said.

Harm Mary Pilon hopes never comes to residents at Elderwood nursing home.

“I don’t want that to happen to anybody else,” she said.

Elderwood declined an on-camera interview with WCAX News and couldn’t provide any details of the incident or comment on the multiple investigations, but a spokesperson writes to Christina Guessferd that “... all appropriate measures were taken, including a prompt notification to the family as well as to appropriate state agencies.”

The facility also says it was told the state declined to investigate after it self-reported the incident on the day it happened.

But Mary Pilon says she was told that investigation is occurring in response to her separate report, filed a few days later. State officials explain that may be because the initial report didn’t meet the two key criteria. but Pilon’s report did.

Officials say national data shows for every case of elder mistreatment reported, an additional 23 go unreported.

They recommend that if you have a loved one in long-term care, you frequently ask whether they feel safe and happy at their facility.

Now, we’re awaiting the results of the Pilon investigation.

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