Agawam woman blames local nursing home for husband’s death


SPRINGFIELD, Mass. (WWLP) – The biggest mistake of her life, is how a woman from Agawam described her decision to put her terminally ill husband in a local nursing home.

“I just went on good faith, that was the biggest mistake of my life.”

She couldn’t share her identity with us due to pending litigation, but she told the 22News I-Team the alarming story of what happened to her husband.

It all started back in 2015, when he was diagnosed with liver cancer. Two years later, he had five tumors in his liver and was taking more than a dozen medications a day.

After spending years caring for him herself, she thought a nursing home would be the best move. “I was very aware of the nursing home, it was very close to home which was excellent and I had never heard anything bad about it.”

Less than 72-hours after he was admitted, her husband was dead. “I was assuming they were medicating my husband… biggest mistake I had ever made.”

She reported the incident to the Department of Public Health in Massachusetts, which then launched an investigation.

According to the findings of that investigation, staff members had admitted that they forgot to medicate her husband for nearly 2-days straight. “Finally the truth comes out in another statement. A young girl says she’s there for orientation. The day is chaotic, she’s rattled, she’s tired. The union managers hands her a prescription order, but she forgot to fax it. That’s where the ball got dropped.”

Nursing homes are required to have emergency kits with medication, but all three nurses who took care of her husband admitted to DPH, they never even checked the kits.

TAMARA: “You believe if it wasn’t for the deprivation of these medications, your husband had longer to live?”

“Yes, I truly believe and I always will and I feel such guilt for it. His body was just too weak to fight off what was happening. When I admitted my husband to that nursing home, my husband was my husband, he was behaving the same way he had been behaving for weeks. We’re talking about a man that had give tumors in his liver, and they just cold turkey-ed him, straight out cold turkey-ed him.”

There are 389 nursing homes in Massachusetts, including 40 in Hampden, Hamshire and Franklin Counties.

The I-Team pulled public records on those facilities from the Nursing Home Comparison Tool, a feature that’s available through the Center for Medicare and Medicaid Services, or CMS.

We discovered that while a majority of nursing homes in the state (251) rank average or above average, 138 rank below average or much below average.

In western Massachusetts, 15 nursing homes rank either below or much below average. Four of them are understaffed.

The 22News I-Team dug deeper into the reports behind the low ratings and were shocked by what we found.

One resident died after a CNA at a nursing home in Hampden County had mistaken a respiratory infection as a cold.

According to the report from DPH, the resident was taken to the hospital at the family’s request.

The nursing home called it a “non-emergency,” but a nurse in the emergency department told DPH the resident was “obviously in respiratory distress.”

Shortly after the resident got to the hospital, they died of multisystem organ failure from pneumonia and a respiratory infection.

The 22News I-Team also found another report from a different nursing home in Hampden County, that said the facility failed to report a suicide attempt to the state because the patient was “dying anyway.”

Those reports were just two of the reports we read, but there were dozens of others.

Springfield Attorney Alan Goodman has represented many clients in cases against local nursing homes. “We had a case in which an elderly patient with dementia rolled out of bed at nighttime and fell against the electric wall heater. She had 3rd degree burns.”

Goodman blames most of the issues on inadequate and low staffing levels. “There’s a definite relationship between staffing and outcome or quality of care. Unfortunately, there’s no minimum staffing requirements on the federal or state level, other than a nurse being present for 8-hours a day.”

Sherman Lohnes is the Director of the Division of Health Care Facility Licensure and Certification for DPH.

He told the 22News I-Team the state sets staffing levels in accordance with the Center’s for Medicare and Medicaid Services. “Staffing needs vary from resident to resident, we require each nursing home to have sufficient staffing to meet the needs of residents. If we find a nursing home does have a problem with staffing, we’ll cite that nursing home and require them to submit a plan of correction to address the problem.”

DPH will continue to make unannounced visits until a problem has been corrected. If it’s not corrected, the state will impose fines, or even freeze admission privileges.

Attorney Goodman told the 22News I-Team DPH conducts a thorough investigation once a complaint has been filed, and they don’t stop until the issue has been correct.

He said that’s why reporting incidents is critical. “Under reporting of these incidents is a major problem. The stats show that 25% to 28% of these incidents go unreported. If the resident or resident’s family complaints to the DPH, this is great for not just them, but all of the other residents and potential residents, because DPH will really come down hard.”

Every time a nursing home is cited, it becomes public record on the Nursing Home Comparison Tool.

Lohnes said while it’s important to consider those ratings, they don’t tell the entire story. Many nursing homes correct issues shortly after they’ve been cited, yet the tool keeps records for up to 3-years.

He said if a nursing home has a low rating, that means you should dig deeper to find out why. “We suggest that you go to the nursing home in person, that you ask questions of the nursing home. What led to the low rating? When did it happen? What have they done to correct the problem?”

The woman who told us her husband’s story said doing your own research is critical. “If you’re going to put somebody that you love into a nursing home, dig deep, do all of your research top to bottom and find out anything you need to know. That’s the one thing I will tell all of your viewers, do not make the same mistake I did.”

Click on the links below to see which nursing homes in western Massachusetts rank below average on the Nursing Home Comparison Tool:

According to the Centers for Medicare & Medicaid Services, the Nursing Home Compare feature rates each facility between 1 and 5 stars.
The nursing home star ratings come from:

  • Health inspections
  • Staffing
  • Quality of resident care measures

CMS then calculates a star rating for each of these 3 sources, along with an overall rating.

“The star rating system can give you important information and help you compare nursing homes by topics you consider most important, but isn’t a substitute for visiting the nursing home. Use the star ratings together with other sources of information, and review the Guide to Choosing a Nursing Home and the Nursing Home Checklist to help you think of questions to ask when you visit the nursing home and determine whether a nursing home fits you or your family members’ needs.”

Centers for Medicare & Medicaid Services

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