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ImagePart 5: What Happened to Mom at Mustang Creek Estates, cont'

On Tuesday, December 31, the whole family was busy all day, moving Dad - and his and Mom’s belongings - from Vitality Court.  We were taking things to three different locations.  Late that evening, when we were moving things into Dad’s room at Mustang Creek (in building "C"), Eric also moved a chest of drawers into Mom’s room (in building "A").  She was completely out of it, appearing to be asleep.  Eric was shocked, but also angry because he was thinking, again, that they were over-medicating her or giving her something she wasn't supposed to have. Why did he think this? Once again - because the staff member had told Jenna the day before that Mom was sleeping because they had given her "pain medication." But he knew, as has been stated several times, absolutely nothing on her medication list made her sleep.  Eric tried talking to her and she opened her eyes and seemed to be listening, but she mumbled in response.  He didn’t know what she was trying to say. He leaned over close to her and said, "Mom, hang in there. I'm going to find out what they're giving you. Don't give up."  She actually mumbled, almost incoherently, "Don't give up." She didn't even open her eyes. She looked like she was “doped up” – this was not at all the way she normally was. Something was clearly very wrong. But he had no idea that in reality, she should have been in the ER at this very moment.

What had Rachel S. promised the family? That if the staff noticed anything wrong or unusual, they would call the nurse or call 911. Eric was still under the impression the staff knew what they were doing - he was just concerned they were intentionally giving her something to keep her sedated.

Early the next morning, on Wednesday, January 1, Eric called Rachel S., who was out of town, and left a frustrated message about his concerns.  He was very angry because he believed the staff were over-medicating Mom.  Rachel called him back and swore that they would do nothing of the kind.  She claimed they would only give her medications from her list, and that if they did otherwise, they could get in trouble with the state. He didn’t really believe her, because if they weren’t giving her more meds than she should have, or meds that she wasn’t even supposed to be taking, he didn’t understand why she was completely out of it and only able to mumble incoherently. Surely - surely! - if she was sick, someone would have known.

All of us were basing this assumption on how staff at prior assisted living facilities had demonstrated at least some basic understanding of when a resident might need medical care. Our parents had lived for several months at The Ivy of McKinney, then at Vitality Court in Allen, and the caregivers/staff in both places had always been cognizant of signs of illness or distress. This, coupled with Rachel's promise that Mom would receive 24 hour care, with staff checking on her every 2 hours, even through the night, led us to assume that these staff members were at least doing their jobs, as described by the Executive Director. That was, after all, the kind of care she was supposed to have, as directed by the doctor who had seen her at Legacy Willow Bend - and Rachel, the Executive Director, knew this. The family would not have moved her to this facility otherwise, as stated before.

Eric's roommate was a caregiver who had worked at assisted living facilities and who helped elderly individuals in their homes; she was licensed and had explained to Eric the training that caregivers were supposed to have, or should have, to work in such facilities. Naturally, then, he thought that these "caregivers" at Mustang Creek had similar training.

The family had no idea, at this point, that the staff were apparently untrained and unlicensed.

After speaking to Rachel, Eric went to Dad’s room in Building C to start unpacking boxes and then went to Mom’s to put some things on her chest of drawers, and once again, she was completely out of it.  He noticed, too, that her lips were black.  Now feeling alarmed as well as angry, he found the woman in charge at that time and demanded to know what medication they’d given her; the woman claimed she had only given her a Tramadol.  Eric found this utterly impossible to believe.  "Tramadol doesn't do this to her!" Eric said loudly. The woman told Eric she had not seen Mom since the day she’d arrived, the 27th, and she said she was very different today, but she didn’t act concerned. She told Eric that Mom had acted like she was in a lot of pain when she tried turning her on her side.  He was concerned because it was lunch time, and he saw other residents in the dining room eating. He asked if Mom had eaten lunch or even breakfast, and the woman was evasive, mumbling something about trying to give her cereal.

"I don't know what's going on," Eric said, "but you better not be giving her anything that's not on her list. And why are you giving her cereal? She's been able to eat more than that!"

Again, the woman was evasive, as if she didn't really know what to say. "You know she's going to the doctor in a couple days, don't you?" Eric asked.

"She's going to the doctor?" she said with a surprised tone.

"Yes - she is supposed to go for a follow up to see her plastic surgeon, and she's also going to see her PCP."

The woman didn't say anything in response but seemed uneasy.

Unfortunately, Eric had an appointment he was late for, so he called his brother Ben and told him that he needed to come right away and check on Mom because something was not right. Ben was already planning to bring Dad over to see her. Ben said he was on his way, so Eric left to get to his appointment.

When Ben arrived with Dad, he noticed immediately that Mom had black, crusted lips. In addition, she was unable to speak normally; she could only mumble. He wanted to find out what the staff knew about her condition and to find out what medications they had given her, so he pressed the alert pendant button on Mom’s neck. When no one arrived, he pressed the alert button again several times. Frustrated that no staff came, he left the room to find staff. The only staff member he could find was Mikayla, who was cooking in the kitchen. He told her he needed to speak to someone about Mom because she needed help, and angrily told her that no one came when he pressed the alert pendant button. He asked who was supposed to help, and she said that a man named James was the staff member on call. She then went down the hall yelling for James. Eventually James came out of a room, and Ben told him that he had pressed the alert pendant button twice and no one had come, and that Mom needed help. Jamesthen felt around on his body with his hands as if looking for something and then said, cavalierly, “I don’t have my pager on me.” Thus, the staff member who was supposed to be on call for help did not have his pager and, thus, was unable to know if a resident needed help.

Ben then asked Mikayla and James what medications Mom had been given, but neither was able to answer. Worried that Mom could have been given an overdose of medication by the staff, Ben called 911.  While Ben was waiting for paramedics to show up, Mikayla asked him why he had called 911, as if she didn't understand why the situation was urgent. When the paramedics arrived, one of them felt Mom and said she was hot to the touch and obviously running a high fever, and, after seeing that she was wearing a very soiled adult diaper, he said he suspected she had a UTI.

At the ER (Medical City Frisco), Dr. P--h told us that Mom did in fact have a very serious UTI and that she was severely dehydrated (her lips were black from dried blood, which resulted from dehydration).  The doctor surmised she had not had liquids for a couple days. Later, after a more complete examination, the doctor told us that she had developed Toxic Metabolic Encephalopathy (TME) because the UTI had gotten bad and had not been treated; essentially the infection made its way to her brain.  TME is a type of brain disease that results from severe infections. The medical staff said she would be in the hospital a couple of days on powerful antibiotics.  Nothing was said about her being in critical condition, though.

We were very upset, obviously, because it had now become clear that the staff at MCE had failed Mom in several ways:

  1. Her condition had declined dramatically from where she had been when she arrived, to the point that she could not speak clearly or feed herself, yet the staff had not realized something was wrong. They had told us they were giving her pain medication but now we had no idea what, if anything, they had actually been doing. Clearly, Rachel S., the Executive Director, had recognized something was very amiss, because she had (wrongly) suggested Mom might need to be on hospice care, when in reality she had an untreated UTI. What Rachel and the rest of the staff should have done was call the nurse that was supposed to be on standby 24 hours a day - or call 911 if they couldn't get a hold of the nurse. They had no excuse for not realizing Mom was ill; they were there with her all day and all night, whereas the family was not; they knew her baseline condition when she arrived on the 27th. It should not have taken someone with much training to recognize that something was terribly wrong.
  2. The staff had clearly not been giving her liquids. The severe dehydration, which was so bad that her lips were dry and crusted with blood, could not have happened in just a matter of hours. And to make matters worse, dehydration would accelarate the spreading of the UTI. When you have a urinary tract infection, it is critical that you stay hydrated to help flush the infection out of the system. But Mom had not been given liquids in possibly as long as 48 hours. This is not conjecture. It was the assessment of the medical staff at Medical City Frisco.
  3. To make matters worse, Mom's adult diaper had not been changed - it was soiled when the paramedics arrived. Add this to the dehydration, and you have a toxic scenario that would have given the UTI full reign in Mom's body.

After spending some time in the ER and stabilizing to some degree, Mom was transferred to a room upstairs.

One of the RNs called Eric that night, wondering what Mom's condition had been like previously.  He asked if she’d been able to swallow, speak clearly, etc.  Eric told him that just a few days before, she’d been fine.  She’d been able to feed herself and talk and move around, other than walking, which she was working on. The RN said this confirmed that the TME had developed rapidly because of the unchecked infection in her body. The mental damage she'd experienced had happened within the last couple days.

The next day, January 2, shortly before 5:00 PM, Eric was on his way to the hospital and had just arrived when he received an urgent call from the hospital saying he needed to come as soon as possible.  He rushed in to find out what was going on, scared and panicked, his heart sinking.  The news was horrifying. Mom’s heart had stopped.  She had indicated to a nurse that she was in pain; the nurse stepped out to get medication and when she returned, Mom was unresponsive.  They were able to revive her and get a heartbeat and moved her to ICU, where she was put on a ventilator, but the doctor said it could happen again at any time. 

That evening, Dad told the nurse that Mom wouldn’t want to be kept alive just to be alive, if she were dependent on machines, so he told them to take her off the machines.  She passed away around 11 pm.

The cause of death recorded on her death certificate, per the attending physician, was PEA arrest due to UTI.

An untreated UTI - untreated because the staff of MCE who were around her 24/7 did not seek medical attention even though she manifested clear signs of distress/sickness, and made more lethal by the fact that she was not given adequate liquids, resulting in severe dehydration.

Continue with Part 6.