Before moving on to the next part of the story, it is critical to understand that the reports we just looked at (and much more) were provided to Mustang Creek before Mom moved in. The staff needed to understand Mom's condition and her needs, and what we expected of them, per the discharge orders from Legacy Willow Bend. Samantha and Rachel S. had promised us that the staff would meet Mom's needs as laid out in those records, reports, and orders. If they had not - then why would we have chosen Mustang Creek over other facilities, including a skilled nursing facility?
When Mom left The Legacy Willow Bend on Friday, December 27, 2019, her son "Ben" accompanied her in the van, and he heard her speak clearly and coherently when she was being picked up at The Legacy, during the ride in the van (when she complained about her neck bothering her), and when she arrived at Mustang Creek.
Upon arriving at Mustang Creek, Ben noticed immediately that no staff was present, but Mom wanted to be moved from the wheelchair to the bed because she said that she was tired from the ride. He phoned Rachel S., who then arrived with another staff member, Mikayla, and the two of them transferred her manually from the wheelchair to the bed. Mom had not been given an alert pendant upon arrival as had been promised by Samantha. When Ben brought this to her attention, Rachel S. told Lewis that Mom would be fine, but he insisted that Mom be given an alert pendant and told Rachel S. that he would not leave until Mom had been given the pendant. After waiting for several minutes, someone eventually arrived with the pendant, and once Mom was wearing it, Ben left.
Mom had continued to text her oldest son, "Eric," daily. Mom and Eric always texted regularly; she never failed to text him at night before going to bed. Eric had been a primary caregiver over the past year, taking her to doctor's appointments, tests, and radiation treatment, had changed the dressing on her wound, and had been a source of encouragement throughout her fight against cancer. She texted at least once a day and often more than that. At this time, she could feed herself and turn her TV on and do most other things she’d done in the past, except for getting up and walking – which she could, as stated before, do sometimes with the help of two people who knew what they were doing. It’s important to reiterate that Legacy’s discharge papers, as shown in Part 2, did not indicate any concerns about her declining in health; she was supposed to see a doctor within a week of discharge, and Legacy provided her current medication list and the dosage and schedule of medications. Mustang Creek was supposed to take over giving her the meds, as promised by Samantha. They also said they would check on her every 2 hours, even through the night. They said they’d take care of moving her from the wheelchair to the bed. They said they’d keep us updated on her condition and of course would get medical help if she needed it. They told us, “Trust us with your mom.” Again - if they had not promised us these things, we would not have moved Mom there.
We had just a few days to get Dad and all of his and Mom's belongings moved from Vitality Court to Mustang Creek in Frisco. It was a chaotic time, and the family chose to trust the staff at Mustang Creek to do what they promised they would and take care of her while we were busy moving Dad. None of us got to see her too many times over the next few days because we were so busy with Dad’s situation. He had to move in on Tuesday, December 31. He was going to be in a different “house” than Mom – as explained before, Mustang Creek is a residential assisted living solution, where about 14 residents live in each “house.” Again, Mom required more care, so she was in a different building, but Dad planned to go be with her during the day. On the evening of Friday, December 27, the day Mom moved in, Eric and his 18 year-old daughter "Erin" went to see her, and Eric put her TV up on the wall. She loved watching TV – it was the main way she passed the time. After they arrived, the first thing she told Eric, sitting there in her wheelchair, was, “All I can say about this place is it sucks.” She didn’t like change, so he wasn’t very surprised. But he did start to worry when Mom said she wanted to get in bed because she was hurting. A staff member named Mikayla came in to use the hoyer lift to move Mom from the wheelchair to the bed. When she had Mom above the mattress, she was supposed to lower her gently, of course, but instead, she let her fall straight down, at least 20 inches. It scared Eric and Erin, and Mikayla acted like she was surprised; Eric asked Mom if she was okay and she said she guessed so. He figured she would yell out if she was hurt, so he told himself maybe Mikayla just wasn’t used to that hoyer lift, since it had just been delivered that morning. He was assuming, though, that she was familiar with the devices and had used them before, but it did bother him that she had made such an error. (He did not know at the time that she was inexperienced and unskilled with use of such a lift.) The incident also frightened Erin.
The next day, Saturday, December 28, Eric had to run numerous errands, including getting some things for Mom and Dad. He got a stand to put her DVD player on, one that would also hold the cable box. Mustang Creek hadn’t hooked up her cable yet and promised to have someone come out hopefully Saturday to do it; otherwise Rachel S., the director, said she’d do it on Monday. So that evening, Eric and Erin went over to assemble the TV stand. When he arrived, Mom was at the dining room table, in her wheelchair, and was finishing a hot dog (feeding herself, of course). She said she’d had some potato salad and also had some beans she was finishing. Eric didn’t stay too long because she was eating and he needed to get back home.
During the day on that Saturday, she had called Eric several times and left messages. He later felt really bad when he listened to one message in particular she had left before he went over to see her. She said in the message that she wanted to talk to him “about this place.” He could not understand everything she said as it sounded as if she was in bed and did not have the phone close to her the whole time, but she said she was scared of the people there. She had never, in all the places she’d been, said she was scared of people. She had let us know when she didn’t really like someone in other places, including at rehab, but she absolutely never said she was scared. She also said they had done something to her that really hurt her. Eric later texted Mom that night, shortly after 10 pm, and said he hoped she had a good night. She texted back “You too.”
Mom had also called Dad that afternoon (Saturday, December 28) and complained to him that the staff at Mustang Creek had dropped her again and had spoonfed her “like a baby.” She asked to be put on speaker phone, and Jenna and Ben heard her make these complaints as well. She was speaking very clearly at the time. We calledRachel S. to complain about these incidents. Rachel S.investigated and called us back, apologizing for Mikayla not using the lift properly and told us that from then on, she had instructed Mikayla not to use the lift by herself.
On Sunday, December 29, no one had a chance to go check on Mom, but when son Eric was out, he bought a couple John Grisham books for her to read. She used to read all of his books but hadn’t read one in awhile, so he thought it would give her something to do, especially since she didn’t have the TV on yet (despite Rachel's promise that someone would come connect the cable on Saturday it didn't happen). At 6:00 pm, Eric texted her to ask how she was doing, telling her heknew she must be bored and also letting her know he'd bought the books. Mom had an iphone as Eric did, and he could see when she read his messages. He saw that she read this message, but curiously, she didn’t respond. This was highly unusual for her because she always responded to his texts. He later wished he had gone to check on her; unbeknownst to him, something was very wrong, though no staff member had alerted him or any of the family .
On Monday, December 30, Jenna stopped by Mustang Creek to drop off some paperwork and Rachel S. told her that she had something she wished to talk to the whole family about. When Jenna asked what it was about, Rachel S. told her that she didn’t think the family was aware how “bad off” our Mom was; since she had moved in, she had noticed that Mom had been declining, but she did not say in what way. In fact, she said she was going to recommend our mom be evaluated for hospice care. This made absolutely no sense. As we have seen in the records from the Legacy Willow Bend, Mom was in good health and all expectations were for her to continue to improve. Jenna was stunned. Before leaving the facility, Jenna went to check in on Mom. She was surprised to see her sleeping soundly, it appeared. Mom did not sleep soundly – never – because of constant discomfort and pain. She was very sensitive to pain, likely because of nerve issues that had arisen as a result of her invasive back surgeries in the past. Paula asked one of the staff why she was sleeping like that, and the woman promptly replied, “Pain medication.” She did not say which "pain medication" she had given her, and Jenna immediately thought it not only strange but suspicious, because none of Mom’s pain medications knocked her out like that, as we explained in Part 2. And she had not been prescribed any new medications. While Jenna was there, Mom received a phone call and Jenna noted how she actually seemed to fumble around as if looking for it on it on her person. Jenna asked if she needed any help. Mom didn’t even seem to have her eyes open and didn't even seem aware that Jenna was there talking to her, and as soon as the phone stopped she went back to sleeping soundly. None of this made any sense to Jenna - but the fact that the staff member had quickly told her that they had given Mom "pain medication" made her wonder if the staff was giving her something not on her medication list. (As we will discuss later, the staff did not even record what they had given to her - at all. Indeed, over the course of the five days Mom was at Mustang Creek, the staff did not record ANY of the medications they gave her, including her prescriptions. We have no idea if they ever gave them to her.)
Jenna expressed concern that Mustang Creek might be “doping Mom up” so they wouldn’t have to deal with her. Eric was worried about this, too, because her description of Mom sounded like something was very wrong. Eric and Jenna did not imagine at the time that something might actually be wrong with Mom - the staff had repeatedly explained her sudden change of condition by claiming they gave her pain medication. Eric also texted Mom again on Monday, wondering if Rachel had done as she had promised and gotten Mom’s cable turned on (she hadn’t, but he didn’t find out until later). Once again, Mom read the message but didn’t respond. Eric grew more and more concerned that the staff were possibly over-medicating her or giving her medications she was not supposed to have.
Continue with Part 5.