Nursing Home Litigation: Patient died at hands of Pathfinder
Suit by ex-husband points finger at health center, too
 
BY NELL SMITH
ARKANSAS DEMOCRAT-GAZETTE
March 5, 2005

The ex-husband of a Benton nursing home resident who died after being run over by a bus filed a wrongful death lawsuit Friday against the state run nursing home and the vocational program charged with her care.

Lincoln Knight, the administrator of Mary C. Knight’s estate, blames Arkansas Health Center and Pathfinder Inc., the vocational program operating under state contract on the nursing home campus, for failing to adequately supervise his ex-wife, according to the lawsuit filed in Saline County Circuit Court.

The 67-year-old woman had been diagnosed with dementia, bipolar disorder and alcohol dependence and was committed to the Arkansas Health Center in 2001 by court order. Shortly after getting off a nursing home bus that transported her to the Pathfinder facilities in April, Knight was found crushed by the bus. The bus driver had backed over her and then drove forward, according to an affidavit filed with the lawsuit.

State officials said at the time they believed the woman may have been trying to commit suicide by lying under the bus. A day before her death, Mary C. Knight was overheard saying, "I just want to die," according to a report issued by the state’s Office of Long Term Care, which regulates nursing homes.

But Lincoln Knight’s attorney, Morgan E. "Chip" Welch, said her death was the result of Pathfinder’s failure to protect her.  "Anyone who suggests that this lady was distraught or depressed or suicidal overlooks the fact that she was also committed involuntarily to that institution, and she was judged incompetent," he said. "One of the things that you have to do when the state has custody of someone who’s incompetent and insane is they’ve got to take care of them."

Julie Munsell, spokesman for the state Department of Human Services, which runs the nursing home, noted that police investigated Knight’s death and ruled it an accident.  "We have always felt like that was — albeit tragic — an unfortunate accident," she said, noting that some policies have been put in place to address general campus transportation issues.

The incident that led to Knight’s death was the second instance in which Pathfinder failed to adequately supervise her, the lawsuit said. In September 2003, Knight left the Pathfinder work therapy building unsupervised and was later found on the ground with her pants pulled down, according to the affidavit that accompanied the lawsuit. A male resident was found over her on his knees with his penis exposed, the affidavit said.

Munsell said the lawsuit was the first time she had heard of the that incident. The Office of Long Term Care did cite the nursing home for violations linked to the bus accident.  "But I’m not aware of any deficiencies cited for the other incident," she said.

The negligence of Pathfinder and the Arkansas Health Center , the lawsuit said, resulted in Knight’s "sexual abuse while at Pathfinder, Inc., mental trauma, and ultimately being run over multiple times by a bus supervised, driven and operated by agents and employees of Arkansas Health Center ."

Knight’s death followed a string of deadly occurrences at the Arkansas Health Center , the state-run nursing home for the mentally ill and the disabled. Between July 2002 and May 2003, the state facility has been the site of at least five deaths caused by or associated with failed policies or staff mistakes.

The nursing home’s latest inspection in November found several less severe violations, including failure to ensure staff knocked before entering residents’ rooms and failure to keep residents’ catheter tubing from dragging on the floor.

A Dec. 20 letter from the state Off ice of Long Term Care states that the center has returned to compliance with federal requirements.

An Office of Long Term Care report issued after Knight’s death said employees at the Health Center failed to intervene by either monitoring or implementing preventative measures. Besides failing to intervene in Knight’s case, the health center was cited for not documenting a resident tripping another resident or developing approaches to prevent tripping incidents.

At the time the report was written, the health center had already initiated 14 efforts to ensure that an accident similar to Knight’s is avoided.

The changes that the health center implemented include:

• - Requiring employees to conduct "walk-around inspections" and serve as "spotters" to guide vehicles that are backing up.

• - Requiring employees to monitor building doors when residents are arriving at Pathfinder.

• - Training staff on these new procedures.

• - Appointing a maintenance action team to determine if vehicle modifications or route changes would help prevent accidents.

The lawsuit names as defendants the insurance companies, both the Arkansas Health Center and Pathfinder, the state Department of Human Services, which runs the nursing home, and the state of Arkansas .