Working 4 You: Daughter Believes Nursing Home Covered Up Neglect in Mother’s Death

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LITTLE ROCK, Ark. — An early morning death. A late night call from a whistleblower. And a daughter who alleges her mother’s death was covered up by the nursing home hired to care for her. In this KARK exclusive, Working 4 You delves into the death of Clara Hoyt, the laws on what nursing homes are required to report and who is held accountable when facilities aim to keep families in the dark on suspected neglect that leads to death. 

An Early Morning Call, a Late Night Revelation
 
Watching the video, Hillary Rudkin smiles, but it doesn’t reach her eyes. 
 
“Obviously it must have been great memories because she smiled. she laughed, and came to life when we visited her, especially with my kids,” she said. 
 
Memories of her mother are bittersweet now, tainted by the knowledge of her mother’s death she learned in the weeks following a phone call at six o’clock in the morning on March 25, 2016. 
 
“Granted, she was sick and sometimes couldn’t remember my name, but then other days to where we could tell we made her whole day,” she said. 
 
Clara Hoyt died at 68 years old. She had been diagnosed with dementia and had suffered a heart attack and a stroke in the years before. Hillary thought she would have more years with her mother, and the nursing home told her Clara died from natural causes triggered by the distress of falling out of bed. 
 
“They said she wiggled her way out of bed, panicked, and scared herself to death and gave herself a heart attack,” Hillary said. 
 
When Hillary saw her mother an hour after getting the call, she says Clara was back in bed and a sheet had been wrapped around her neck. 
 
“They told me it was for when rigor mortis sets in they don’t want your mouth to fall open,” she said. “I thought it was odd, and something inside me told me to take a picture of her there. I’m so glad that I did.”
 
The Pulaski County Coroner’s office bypassed an autopsy after police, who were called to the scene with EMS, reported no signs of “criminal or suspicious activity,” according to the police report. But Hillary would get a call a day later from a whistleblower who told here that Clara’s death at Pleasant Valley Nursing and Rehabilitation could have been prevented. 
 
“She told me that my mother had actually died caught between the mattress and possibly the wall,” Hillary said. “I was shocked. I immediately tried to call the administrator, and I didn’t hear from her for two days. 
 
Deceit and Death: Pleasant Valley Nursing Home Denies Neglect
 
When Hillary was able to speak with the nursing home administrator, she said the deceit went deeper. 
 
“Basically she got on her knees, next to the bed,” Hillary said. “She said my mother’s head was kind of laying on the mattress. When I asked if that could have any way caused her death, the administrator said no, no. We believe she died from a heart attack.” 
 
The results of a private autopsy, though, proved Clara Hoyt had died from positional asphyxiation. Her air flow was cut off, which was consistent with her head being caught between the mattress and the bed rail. 
 
“They’re [the nursing home] is supposed to do their job.They take all of her money, and it’s up to them to provide her the best care,” Hillary said, holding back tears. “They didn’t do that  and as a result, I no longer have my mother. My kids no longer have their grandmother.”
 
According to the coroner’s office, the nursing home never reported the death to the office nor did the nursing staff inform the coroner’s office that it might have resulted from suspected neglect or abuse. 
 
“We really rely on the nurses reporting the death to be truthful,” said Pulaski County Coroner Gerone Hobbs. “If the police come to the scene – of the nursing home, the police agency will call us. But it still falls back on the nursing home to report the death.”
 
This isn’t the first finding for the facility. DHS cited the home for failing to attend to fall risks for a number of residents prior to Clara’s death. Two more complaints were substantiated that involved hazards in the living quarters, among others.
 
“She Died Alone and Scared”
 
According to the Pulaski County Coroner Investigation file on Hoyt’s death, and documents from the Office of Longterm Care inside the Department of Human Services, that never happened. The pathologist alerted the Coroner’s Office to the autopsy findings. Hobbs reopened Clara’s file, and started an investigation. According to documents, Hobbs told the Office of Longterm Care that he received three different stories from the three employees who responded to Hoyt’s room that morning. 
 
The nursing home finally reported Hoyt’s death to the Office of Longterm Care nearly two weeks afterward, once the coroner’s office contacted them to arrange for interviews for its investigation. Arkansas law requires nursing homes to notify the coroner’s office of deaths resulting from suspected maltreatment. 
 
 
“That’s what is scary about this case is they almost got away with it,” said Shawn Daniels, Hillary Rudkin’s attorney with the Hare Wynn Law Firm. “They absolutely failed to truthfully report as required by law. You can have all the regulations you want, but it still requires integrity from the home.” 
 
The Office of Longterm Care also has regulations regarding incidents, accidents and unusual deaths to be reported immediately but no later than 24 hours. Pleasant Valley did neither. In fact, its own documents show it did not fill out the report to the office, until the day it was contacted by the coroner that there were questions regarding Clara’s death.
 
Willful violation of these reporting requirements is a misdemeanor under Arkansas law
 
The Office of Longterm Care did not cite for Pleasant Valley for failure to report, and it hasn’t explained why clearly at this point. Although, they did note all maltreatment cases are referred to the Attorney General’s Office. Daniels confirms Hillary Rudkin is working with the proper authorities.
 
A DHS spokesperson did confirm the penalties the center was cited for carried some hefty civil penalties, saying, “The deficiency at F323 carried a civil money penalty of $4,850 per day March 25-April 12, 2016 and $300 per day April 13 to date of compliance (identified on revisit from OLTC) for a total of $98,850.  Because CMS grants a reduction in penalties if there is no appeal, the final amount paid by the facility was $68,252.  Deficiencies, if cited, for F225 and 226, would not have increased the CMP or have resulted in any additional enforcement measure against the facility.”

According to records we obtained, Pleasant Valley did conduct an investigation after Hoyt’s death. In those records, one of the nurses alleges Hoyt’s head was between the mattress and bed rail, another claimed she wasn’t wedged at all. Photos of at least one staff member showing how he found Hoyt does show his chin resting on the rail, her head between, laying on the mattress.

In order to prevent any further accidents, the nursing home claimed it was evaluating bed rail use for clients and making sure there were no hazards. They also wrote that an in-service training had begun. 

 
Reenactment photos during the coroner’s investigation show what really happened.
 
“The truth is she was asphyxiated, because of their neglect in creating the environment that caused her to choke,” Daniels said. 
 
A Nursing Home on Notice: Does that Mean Neglect?
 
The DHS investigation noted that interviews with staff revealed Hoyt was known to wiggle and reposition in bed, in response to a skin condition that caused her to itch and become uncomfortable.
 
According to staff members, despite Clara being wheelchair bound and dependent on staff to help her in and out of bed, she could wriggle below the bottom of the bed rail in as little as 20 minutes. She had fallen out of bed before. 
 
Still, staff that night said they were only checking on her in two hour shifts, having repositioned her earlier in the evening for the same shifting.
 
“Is there any way someone is hanged on a bed rail without neglect?” KARK asked Daniels.
 
“I just don’t see how. We see corners being cut all the time in nursing homes. If you look at the shift sheets, you can see they were understaffed, and if they had been properly staffed and checking on her regularly because of that risk, she might be alive right now and we wouldn’t be here.”
 
Clara Hoyt had a history of falls. According to the Pleasant Valley Nursing and Rehabilitation treatment notes, she had been assigned a bed alarm due to her consistent falls out of bed in the past. There is no note regarding a bed alarm on March 25. 
 
“For some reason that’s still unknown, why they removed that alarm,” Daniels said. “It had protected her in the past, but it was not there that morning. And it might have saved her life.” 
 
The coroner determined that between 3 and 5 a.m. Clara fell out of bed; her head wedged in the gap, and when she was finally found, she didn’t have a pulse and was turning blue.
 
“To think  how scared she was. What must have been going through her mind being all by herself, that’s hard for me,” Hillary said. 
 
Hillary Rudkin has since filed a wrongful death, medical malpractice and Deceptive Trade Practices suit against the nursing home. According to Daniels, it’s the only way to create accountability for homes like Pleasant Valley.
 
“They created the very thing that caused her death, and unfortunately we see that all the time in the nursing home industry,” Daniels said. 
 
Other Residents Remained at Risk
 
The Office of Longterm Care found none of the stafff at Pleasant Valley had been trained on proper bed rail use or low-air mattress suffocation dangers either before or after Clara’s death. At the time of the survey, two other residents with the same circumstances as Clara were evaluated for safety in their bedding. Investigators found that for those residents, gaps in the mattresses were at least 3 times as large as recommended for safety, and staff seemed oblivious. 
 
“Checking for and eliminating gaps does not take super heroic measure,” Daniels said. “The dangers of these non-conforming mattresses and the choking hazard that gaps pose has been researched and documented for 20 years. This is just safe practice.” 
 
Despite the nursing home claiming in-service on bed rails had been started, the administrator eventually confirmed to OLTC no paperwork was handed out, the training was never done. The surveyors placed the home in Immediate Jeopardy status, because the lack of training and the gaps created a risk of serious injury or death for several residents.
 
“They’re kind of at the mercy of the nursing home. And I just have to pray they get someone who isn’t just there for a paycheck,” Hillary said. “I struggle with the guilt a lot. I was the one who made the decision to place her in the nursing home. I thought I was doing what was best for her. I find myself a lot still, apologizing to her that I’m sorry.”
 
Nobody Replaces Mom
 
Hillary knew her mother’s health would eventually go down hill and that her memory would ultimately fail at some point. But she firmly believes her mother would have had more years of happy visits ahead had the nursing home simply cared for her mother the way they should have.
 
There’s no more talking to mom.To me — nobody replaces mom,” she said. “She was taken too soon so I’m very angry and very upset she’s not here anymore.”
 
We reached out to Pleasant Valley Nursing home’s administrator about Clara Hoyt’s case. We asked three specific questions — why her death wasn’t reported immediately, how the facility investigated her death, and if it had a policy regarding death investigations.
 
Administrator Shelly Savage gave us the same response to each question saying, ” Our company policy is to not comment on the care we provide residents.”
 
According to the Department of Human Services Office of Longterm Care, it did not report to law enforcement the nursing home’s failure to report Clara’s death, despite the law being clear that purposefully not reporting is a misdemeanor offense. Ironically enough, someone who makes a false report against a nursing home for suspected abuse or neglect can escalate to a felony.
 
To follow this story and all of Marci Manley’s coverage, click here for Facebook or here for Twitter

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KARK Working 4 You is committed to highlighting issues that are important to Arkansas. If you have a story that needs to be covered, call Reporter Marci Manley on the Working 4 You Tipline at (501) 340-4448 or email at working4you@kark.com.

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