State officials are revoking Canterbury Gardens Alzheimer Care center’s operating license, saying staff mistakes and ineffective security measures are to blame for an 88-year-old patient freezing to death earlier this month.
Some safety hazards were uncorrected even three days after the woman’s death on Dec. 6, according to state officials.
The Longview facility, located at 1457 Third Ave., can continue caring for its 57 current residents while an appeal takes place, but it’s immediately barred from accepting new patients.
The state Department of Social and Health Services said it will monitor patient care and will require staff to accompany patients when they are out in the center’s courtyard.
Norma Sheldon’s body was found in an enclosed, open-air courtyard in frigid conditions after staff missed a required, hourly bed check. The Alzheimer’s patient was wearing only a nightgown in the 28-degree weather and died from hypothermia. Her family has hired a lawyer and says it will work to prevent further incidents.
The state’s revocation action is one step down from an immediate, emergency closure and means state officials fear for the safety of patients in the facility, according to the revocation letter.
“We don’t do revocations lightly,” Irene Owens, interim director of the state’s Residential Care Services, a division of DSHS, said Monday. “This was a very serious situation.”
Canterbury officials said they’re confident they can work through the appeal process and fix all of the state’s concerns. They have 28 days to serve notice of the appeal.
“We are completely aware of the Department of Social and Health Service’s concerns, and we are already in the process of taking every measure necessary to satisfy each issue,” according to a prepared statement from Olympia-based Koelsch Senior Communities, which owns Canterbury Gardens and three other retirement homes in Cowlitz County. “We are fully prepared to do everything necessary to earn the department’s trust in our ability to ensure the safety of our residents.”
If the appeal is unsuccessful, the center would eventually have to close. Appeals can take several months and even up to a year, Owens said Monday.
A investigation of Sheldon’s death included daytime and nighttime visits and interviews with staff and reviews of some patients. The violations investigators found “resulted in the death to a resident and put 61 other residents at risk for accidents or injuries,” the revocation letter states.
Investigators found that:
• A worker failed to do the midnight bed check, losing track of time while sterilizing wheelchairs and walkers and not checking the time until 12:50 a.m. Sheldon was found a few minutes after 1 a.m.
• Not all doors to the courtyard had operational locks or alarms. Some doors also had no keys available.
• Of the alarms that were on, some were too faint to be heard clearly.
• Another patient was known to try and leave the facility and had removed an alarm from one of the courtyard doors.
• There was a policy to lock courtyard doors in case of snow or ice, but not one for cold temperatures.
• Following Sheldon’s death “there was inadequate response by the administrator to ensure all doors exiting to the courtyard were lockable and alarmed.” A door without an alarm was pointed out during the Dec. 8 inspection visit and staff placed a barrier in front of it. On Dec. 9 — when inspectors returned three days after Sheldon’s death — the door still did not have an alarm and the barrier had been removed.
• There’s confusion about how often Sheldon should have been checked after she injured her hand in the courtyard on Nov. 22. Some records said every 15 minutes, others had that crossed out. There’s no record such checks were being done at the time of her death. Her husband, Don Sheldon, remembers two other times she fell in the courtyard, but he said he doesn’t remember being told of the Nov. 22 incident cited in the state report. Just going by the two previous times, though, Sheldon said it’s “ridiculous” that his wife was allowed to wander out into the courtyard at night.
Don Sheldon hasn’t seen the state report Monday, but he said he’s glad the problems are getting attention.
As for Canterbury Gardens, Sheldon said he would be sad to see it closed because of all the workers and patients there. If the state certifies that all the problems are fixed, he said he’d be okay with it remaining open.
“I don’t have anger about this,” he said. “I’m very disappointed and I don’t want it to happen again. … I want someone to show me it’s going to be corrected.”
He buried his wife Saturday and said the service was standing room only.