Neglectful healthcare causes death in nursing home – two sides of a DRE investigation

A month later, after Donna had died, Mrs. Sonnenberg called Alan Litwiller, asking what DPH had learned. This was the first Litwiller had heard of the matter. He asked Helen Byrd where her report was; she said there had been no investigation but would not explain why. When Litwiller assigned a doctor-nurse team – Bernard J. Schaffer and Regina Kristopaitis – to conduct the neglected investigation, Byrd gave him a hand-written preliminary report of surveyor Washington’s January 28 visit.


This investigation had been Washington’s first, done apparently without supervision. She had looked at Donna’s nursing home records and spoken with Dolores Lindenbaum and with a nursing supervisor; she reported that there was inconclusive evidence of neglect. It remains unclear why Byrd suppressed or ignored Washington report.*

Kristopaitis and Schaffer toured Mill View and reviewed Sonnenberg’s chart on February 23. Kristopaitis generally noted Donna’s deterioration. She remarked on the paucity of nursing observations and lack of vital signs in the chart as well as the “lack of professional staff involvement in resident evaluations.” Kristopaitis also pointed out that unlicensed, unauthorized workers – nurse technicians – had apparently taken Aren’s phone orders for medication changes, that the doctor hadn’t countersigned these orders within 72 hours as required by DPH regulations, and that the doctor hadn’t physically examined Sonnenberg within five days of her admission, again in violation of DPH regulations. She told the Mill View administration of these deficiencies and gave notice of type B and C violations. These violations resulted from deficiencies not only in Sonnenberg’s chart but in other patients’ charts as well; the type B and C violations were for Mill View’s practices concerning all patients, not just Donna Sonnenberg.


About two and a half years later, when we spoke with Kristopaitis about her investigation, she recalled the poor condition of the records. She especially recalled how blase Mill View officials were when she questioned them about unlicensed nurse technicians giving medications and taking physicians’ phone orders. She found their unconcern unbelievable . Schaffer also outlined Donna’s decline during January. He wrote of the patient chart’s lack of evaluations, vital signs, and laboratory work, and the fact that unlicensed *Byrd was later fired for her alleged misconduct in this and other situations. Allegedly she diverted investigations of homes in return for financial and other favors. She appealed her dismissal; as of this writing, the matter is pending.

Nurse technicians had taken Aren’s phone orders and changed Donna’s dressing. Touring Mill View, he observed the home’s need of maintenance and housekeeping. He found almost every room, including the central medical supply room, ill kept. In his summary, Schaffer made six recommendations:

1. Review, evaluation and implementation of home’s resident care policies to assure necessary followup and awareness of resident status with involvement of all disciplines of house’s personnel. (Administrator, Medical Director and Director of Nursing).

2. Upgraded documentation to be more meaningful and inclusive of all phases of resident care. (Examinations, vital signs).

3. Timely resident visits and greater awareness of the more critically ill in the home. (Daily critical resident list).

4. Care, treatment and documentation by licensed personnel.

5. Review of resident care by utilization review.

6. Upgraded surveillance and monitoring of residents.


Schaffer and Kristopaitis gave Alan Litwiller their report on February 26, telling him the home had committed type B and C violations against several patients, and that the home’s treatment of Donna Sonnenberg also constituted type B and C violations, not type A. Litwiller told Mrs. Sonnenberg the results of the investigation. She was dissatisfied. She told Litwiller that she thought the violations against Donna should be type A; she also said she wanted to sue both the physician and the nursing home. We should pause here to explain the DPH procedure on receiving a complaint. The department is supposed to investigate alleged type A violations within 24 hours, B and C violations within 30 days. The violator has to correct a type A violation immediately, or, if the department agrees, within 15 days. With type B and C violations, the violator submits a plan of correction within ten days. If the department accepts it, the facility has up to 90 days to correct patient-related deficiencies. If subsequent inspections show that the violations continue, DPH may accept a new plan of correction or impose fines, which are figured in a very orderly, comprehensive way. DPH may fine a violator immediately for a type A violation, but in type B and C violations only after finding an accepted plan of correction unmet. The department may also suspend or revoke a facility’s license for such violations.

In any case, the facility may ask for a hearing to contest the penalties. Because of Mrs. Sonnenberg’s dissatisfaction, and because of Helen Byrd’s questionable handling of the initial complaint, the department paid continuing attention to the case, including two internal investigations about how the complaint had been handled. About a month after Litwiller told them the investigation’s results, the Sonnenbergs called Fred Uhlig, DPH deputy director. Apparently they convinced him that the B and C violations might be inadequate; he told Litwiller that he wasn’t satisfied with the classifications and would like a review and new determination. Litwiller visited the Sonnenbergs on the first of April to get their permission to review Weiss Hospital’s files. In his memorandum to his supervisor William Irvine, Litwiller expressed his reservations about the case and about the initial type B and C determinations:


“It appears as if the facility [Mill View], the physician and the hospital share the blame, if in fact blame could or should be assessed.”

He points out the possible inadequacies on the part of each: There should have been more professional nursing involvement with the ramifications of better treatment of the ulcer, better nursing observations, better documentation on the medical records, and consequently a more aggressive approach to the attending physician. The attending physician appears to have not been as responsive or aggressive in the medical supervision of this resident as he should have been. . . . The records do not indicate if the facility Medical Director was informed of the resident’s condition and apparent lack of appropriate attending physician involvement. The Medical Director should have been informed and could have superceded in this resident’s care. The hospital medical records indicate that there were as many as six physicians involved with the resident’s plan of care in the hospital. … It is entirely possible that the resident could have contracted an infection during the decubitus debridement or the insertion of the pulmonary artery catheter. . . . I realize that there is a fine line between minimal care, inappropriate care, and neglect. I believe this holds true equally with the nursing home, the attending physician, the Medical Director, and the hospital.