World of Hurt: Those Lost and Those Left Behind

As a star running back with Chicago Bears in the 1940s and 1950s,
George McAfee was known as explosive athlete endowed with speed and agility. His elusiveness
helped his team win national championships in 1940, 1941 and 1946.

To his
daughters, the Pro Football Hall of Famer was simply their witty and devoted
dad, who enjoyed being around his children and grandchildren and seldom spoke
about his football days after retiring from the game and moving to Durham, N.C.,
to run an oil distribution business.

In the late 1990s, McAfee began showing
symptoms of dementia, a brain disorder marked by memory loss and impaired
judgment.  He started to experience
periods of confusion, forgetting people’s names and getting lost during routine
trips to the post office and bank.

Shortly after his wife’s death,
McAfee moved into a facility for seniors in North Carolina. But he developed a reputation for escaping the confines of the secure
memory care unit to go outside for walks. He escaped so many times that his
family ultimately decided to transfer him to a facility in Georgia, where he
would be closer to one of his daughters and have limited access to the outdoors.

In June
2006, McAfee moved into Cypress Court, a 60-bed assisted living facility
specializing Alzheimer’s and memory care in Decatur, a suburb of Atlanta. Although
McAfee suffered from dementia, he was still able to recognize family members,
joke around with staff and relatives, sign autographs for fans, and occasionally
go out to eat with relatives.

At first,
Cheryl Morgan, one of McAfee’s daughters, said the family was satisfied with
the level of care at Cypress Court. That began to change after Emeritus
purchased the assisted living facility in December 2006. Morgan
said she began to see a dramatic shift in the level of care.  

Caregivers whom the family
considered very attentive to their father’s needs left. Staff constantly rotated
on each wing, making it difficult for residents suffering from dementia to connect
with anyone, she recalled.

Housecleaning and residents’
personal hygiene seemed inconsistent. Morgan said she became so concerned about
the facility lack of cleanliness that she began to stick pieces of paper in the
bed sheets to keep track of how little her father’s bedding was being washed. The
floor was always sticky, she recalled.

“Daddy’s appearance
changed,” Morgan recalled. “He was often unshaven, his hair was dirty, he
dressed himself but he was dressed in the same clothes over and over and over
again and his laundry wasn’t being done.”

On the
night of Feb. 20, 2009, McAfee left his room and went wandering through the
facility. A caregiver eventually discovered him holding a large bottle of
liquid dishwashing detergent in his hand. He had a dark red and blue substance
on his lips. She realized that McAfee had swallowed the dishwashing detergent,
a toxic substance that was supposed to be kept in a locked cabinet, and called
911. 

When the
family arrived at the hospital, they found their father in the intensive care
unit. He was unconscious and on a ventilator. The dishwashing detergent had
destroyed the lining of his lips, esophagus and lungs.

“His face
almost looked like what you picture in a horror story of a death mask,” Morgan
recalled. “I mean it was just horrible.”

At one
point, McAfee did manage to sit up and open his eyes and look at his daughters,
Mary Jeanne Stouffer, McAfee’s other daughter, recalled. “And we said, ‘daddy,
we’re right here.’” Morgan said.  

Eleven days
after swallowing the dishwashing liquid, McAfee died. The cause of death,
according to Gwinnett County’s chief medical examiner, was the delayed effects
from ingesting sodium hydroxide. 

After his
death, his daughters grappled with the circumstances that had led their father
to suffer so much in the final days of his life.

Budgie Amparo, Emeritus’s executive
vice president for quality services, expressed regret for the pain and
suffering the family endured as a result of the incident, but maintained that
this event had been an isolated mistake by one staff member who forgot to lock
up the dishwashing liquid.

In late
April 2009, the Georgia Department of Human Resources cited Emeritus for
failing to provide 24-hour protective care and watchful oversight of McAfee.
During the same investigation, the facility was also cited for an unrelated
medication error. The agency fined Emeritus $601 for the citations.

When
McAfee’s daughters learned of the amount of fine, they were distraught. 

“In my
opinion, I think they just got a slap on the wrist,” Stouffer said. “And I’ve
said all along, had this been a daycare facility that, where a child died, the
place would have been shut down, and to only get a fine of $601 I just think is
outrageous.”

McAfee’s daughters
also came to believe that their father’s death was not the result of a
temporary lapse of one employee, but of more systematic failures at a company
more concerned with saving money than providing a safe environment for
residents. After bringing a wrongful death lawsuit against Emeritus, the family
discovered that caregivers had repeatedly raised concerns about insufficient
staff at The Court at Decatur prior to the incident.

In depositions, resident assistants – the frontline caregivers
tasked with helping seniors with their basic activities – testified that they
made repeated complaints about understaffing.

“There were people falling on the floor that we – we
couldn’t pick them up,” Melanie Slater, the resident assistant on duty during
the incident, testified. “There was help needed with their medications. People
weren’t getting their medications on time, because we were running late. There
was more than one job to do especially in the morning. When I worked day
shifts, we needed more people there to help while we were giving meds.”

Since the incident, Emeritus has
installed self-locking cabinets in their facilities to ensure safe storage of
toxic chemicals, Amparo said. 

“The loss was very painful, painful not
only for the family, painful for us, painful for our staff,” Amparo said. “But
then again, it’s an accident that did occur.”

McAfee family
reached a settlement with Emeritus for an undisclosed amount.

At her
small home, up a long dirt road in the small town of Auburn, Mass., Angenette
Stewart built a beautiful garden. She planted flowers, herbs and spices,
zucchini, peppers, cabbage, and cherry tomatoes.

“It was
like living in botanical garden,” recalled her son, Anthony Bostic.

When
the flowers started to wilt and the vegetables began to rot, Bostic and his
siblings realized that their mother’s mental capacity was starting to
deteriorate. Shortly thereafter, they realized that she could no longer live on
her own.

At first,
the family paid relatives to move in with Stewart, determined to keep her in
her own home. But Stewart began to have sudden bursts of anger and bouts of insomnia. She
went from being a “sweet little old lady,” to “a little storm,” Bostic said. When
the family put Stewart in adult day care, she started wandering out of the
facility and getting lost, unable recognize the familiar surroundings of her
hometown.

In early August
2004, the family moved Stewart into the Lodge at Eddy Pond, an assisted living
facility now renamed Emeritus at the Eddy Pond Campus.

“Emeritus
assured us that they were monitored inside the room,” Bostic said of residents
at Eddy Pond. “There was a section [of the building] where she could wander but
couldn’t get out.”

But it
turned out that Stewart was not as safe as she seemed.

On Feb.
22, 2005, the Elder Abuse hotline at the state Executive Office of Elder
Affairs received a disturbing call from an employee at the assisted living
facility, alleging that a resident had sexually assaulted Stewart several times
in the facility’s memory care wing for Alzheimer’s and dementia residents. The
caller alleged that staff had been aware of the attacks, but had done nothing
to stop them.

Adult Protective
Services and the state’s Assisted Living Ombudsman program opened investigations
into the allegations.

According
to agency reports, two nurses who had worked at the Lodge alleged that the  director, Lori Toombs, was aware of the
assaults, but had chosen not to report them to authorities or to take
preventive action. One nurse stated that Toombs had said Stewart and the other
resident involved in the incidents were “both adults.”

Another
nurse told investigators she had asked Toombs if she should notify Stewart’s
family about the assaults and was told, “there was no reason for them to know.”
Toombs acknowledged in an interview with the ombudsman that there had been “a
couple of incidents” but minimized their significance.

In reports,
state investigators expressed frustration with what they described as inconsistent
answers and a lack of cooperation from Emeritus.

An
investigator from Adult Protective Services reported that she got different
answers “every time she asks a question.” When the ombudsman asked Toombs for a
timeline of events regarding the incidents, Toombs told her that the timeline
would have to be sent to the corporate office first for review before she could
release it to the ombudsman.

Mary
Hagarty, Emeritus’ regional director of operations, told the ombudsman that employees
had followed company policy. She maintained that employees had documented the episodes
and took steps to prevent future incidents from occurring, including more closely
monitoring Stewart.

The
ombudsman disagreed and stated that it was clear that the facility had not put
an adequate plan in place after the first incident since subsequent sexual
assaults had occurred. The ombudsman also maintained that the executive
director and other Emeritus employees had failed to follow the company’s
policies on abuse and neglect.

In May
2005, the state Executive Office of Elder Affairs concluded that Stewart had
been abused due to the facility’s failings.

Stewart
moved to Queens, N.Y., to live with her family. She died at 81 in May 2005. 

That March,
her family had filed a lawsuit against Emeritus, naming Toombs, the facility director,
and others. Emeritus, conceding no wrongdoing,  settled with the family under
confidential terms.

Toombs declined
to comment.

For most
of his life, Richard Borrack worked as a carpenter in the Treasure Coast region
of Florida, constructing buildings using Spanish revival architecture. He also
taught carpentry in the Palm Beach County School District.

In 2005, Borrack,
then in his early 70s, began to become forgetful, his family recalled. He
started making frequent trips – sometimes three times a day – to the bank
to check his account. He’d forget where he parked his truck, spend all day
looking for it, and then walk home. His eating habits became erratic.

“There
would be food in the refrigerators and he wouldn’t eat it,” his son, Rick
Borrack, recalled. “Or he’d only eat ice cream. He’d say he didn’t have any
food when there was.”

Still,
despite his mental decline, Borrack remained physically healthy, his family
said. He continued to run two to three miles a day on a treadmill and was a
strong swimmer. 

In 2009,
Borrack moved into Emeritus at Jensen Beach, an assisted living facility near
his children with breathtaking views of the Indian River. During an initial
tour of the facility, the family had been impressed with the beautiful marble
floors, suede wall coverings and crown molding.

Despite Borrack’s
tendency to wander, the family told the facility they did not want their father
placed in memory care, a secure unit where the residents’ movements would be
monitored more closely. Looking back, the family now wonders whether they made
the right decision. But they maintain that staff assured them  their father would not be able to leave the
facility.

“We
decided it was not the best thing for him [to be in memory care],” Rick Borrack
said. “We were worried he would feel trapped in memory care and act out. On the
assisted living side, he believed he was living in a luxury hotel. We believed
he would get supervision. They also offered to provide him with one-on-one
nursing if he needed it.” 

At the
facility’s urging, the family enrolled Borrack in the local sheriff’s Project
Lifesaver Program, and put a tracking bracelet on him so local law enforcement
could monitor his whereabouts.

But on the
morning of July 26, 2010, Borrack slipped off his ankle bracelet. Sometime that
evening, he walked out of the facility and hasn’t been seen since.

After his
disappearance, his children scoured the beaches and roads looking for their
father. The Martin County Sheriff’s Department enlisted boats, police dogs,
helicopters and ground teams to trudge through swampland in the hope of finding
him and publicized his disappearance in the local media. Family and friends,
including carpenters who had been trained by Borrack, joined the
search. His son, David, spent 38 days searching in the woods, tracing and
retracing the path from Emeritus to his father’s old house in Stuart, Fla.

Family
members remain haunted by his disappearance.

“I can’t
pass an old person without taking a second look,” Rick Borrack said.

During an
inquiry into the incident, state investigators determined that the top administrator
at Emeritus at Jensen Beach had been notified that Borrack had taken off his
monitoring bracelet early in the day, but did not take adequate steps to ensure
his safety.  The agency
imposed a $2,000 fine. 

In late
January 2012, the family filed a lawsuit against Emeritus alleging negligence. The
case has been ordered into arbitration.

Emeritus declined
to comment specifically on the case to ProPublica and PBS “Frontline.”  In a written statement to  news media in the aftermath of Borrack’s
disappearance, the company said it sincerely regretted the pain and trauma the
Borrack family had experienced since the incident. “Mr. Borrack was a valued
resident at our Jensen Beach community and we feel we’ve lost a member of our
own family,” the statement said. 

As a
member of the U.S. Air Force’s security police, Herbert  Packard Jr. lived on bases in three
states and traveled the world.

But it was
in Colorado Springs, where Packard was stationed at the Air Force Academy, that
he and his family eventually put down roots. For most of his life, Packard was
the rock of the family, according to his daughter, Peggy Packard, whether he
was mediating family disputes, using his sense of humor to defuse tense situations,
or taking care of his wife when she was dying of cancer.

Looking
back, Peggy Packard thinks her father was aware of his mental decline long
before the family was. After spending years volunteering at the local library
to help adults earn GEDs or learn English, he abruptly stopped.

In 2006,
his daughter started to suspect that he might be suffering from the early
stages of dementia. He tried to make Hamburger Helper and couldn’t follow the
directions on the side of the box.

The family
brought in home health aides to assist him with cooking so he could remain in
his home. Then, in June 2008, Peggy Packard received a phone call from her
father’s neighbors, who told her that he was locked outside of his house in
short sleeves and tennis shoes. It was 37 degrees outside. He had been out
there for hours.

The family
looked at several senior living facilities. The first felt too institutional. At
a second one, many residents were still in their pajamas at lunchtime. Finally,
a social worker encouraged them to look into Emeritus, which operated an memory
care facility in Denver, near Peggy Packard’s home. During the tour, the family
was impressed by the “home-like” environment and the activities the facility
offered.

“They took
people to the gardens, museums, and baseball games,” Peggy Packard recalled.
“We liked that. We didn’t want my dad to feel like a prisoner.”

Packard moved
into the facility in June, 2008 and for most of the next three years seemed
relatively happy, the family said

That all
changed on Saturday, Oct. 29, 2011, when Packard walked into the room of
another resident at the facility. According to investigators, the
resident, who had been admitted to the facility with a diagnosis of a traumatic
brain injury, became agitated when others entered his room, believing that they
were removing his belongings.

The man
attacked Packard, knocking him to the floor. The assault left Packard with a
broken hip, a fractured finger, and bleeding in his brain.  The 79-year-old died about two months later.

After the
incident, investigators were unable to find evidence that Emeritus had
evaluated the resident who committed the assault before he moved in. They also
could not find a care plan indicating that the facility had identified the
resident’s territorial behaviors or had taken steps to manage it and protect
other residents from potential abuse. 

State
investigators with the Colorado Department of Public Health and Environment cited
the facility for failing to protect Packard and fined Emeritus $500.

“We were
paying over $5,000 a month for my father’s care, and that’s all they were
fined,” said Peggy Packard.

The
company declined to comment on the incident.

Merle Fall
spent only nine days in Emeritus at Ridgeland Pointe, a facility in the suburbs
of Jackson, Miss., before she plunged from a second-story window, a fall that led
to her death three days later. She was 83 and suffered from dementia.

Fall’s
daughters, Diane Phillips and Linda Walley, said they decided to search for a place
where their mom could receive direct supervision after her behavior at home
became unmanageable. Fall had become combative, and had developed a propensity
for wandering off. “She’d fight with her caregivers,” Phillips said. “She was
confused. She thought she had a baby.”

When the
family contacted Emeritus at Ridgeland Pointe, the company sent out a nurse to Walley’s
house.

“She came
in, shesat down right there on the couch with mother,” Walley recalled. “She
reached over and held mother’s hand. And she never asked questions. As a matter
of fact, it was only later that I understood that she was hereto evaluate
mother, to find out whether she was suitable for Ridgeland Pointe. Because all
she did was talk about what a great experience it was going to be.”   

As the
family explored long-term care options, Emeritus employees touted Ridgeland
Pointe’s top-notch memory care unit, which was located on the second floor of
the facility, Phillips recalled.

“They said
she’d get a lot of individual attention,” Phillips said. “We thought that
because it was private pay they’d have better staff than a Medicaid/Medicare
facility and we wanted her last days to be as good as possible.”

But
problems quickly surfaced. Three days after Merle moved in, Phillips visited. Her
mother was unclean. She smelled like urine and was wearing the same clothes
that she wore into the facility, Phillips contends. Emeritus denies this claim.
 

“We were happy to pay the
money if we had gotten the care they promised us,” Phillips said. “We would
have been happy to pay whatever it took to have her taken care of. But they
didn’t do anything. She wasn’t clean. She wasn’t fed unless one of us was there
to see it.”  

On the
night of March 5, 2010 Fall was restless and agitated. She kept wandering
around the memory care unit, according to statements made by the staff on duty  One said Fall was scrabbling at the lock
on the window in her room at about 2 AM. At some point she tried to bribe two employees
into driving her to Hattiesburg, according to the deposition of an Emeritus
nurse. The next morning, at about 7:10 a.m., Emeritus employees discovered Fall
in the bushes beneath a second-story window. Her tibia had snapped, the jagged
edge of the bone jutting out through the skin on her leg; her brain was
bleeding..

           
“We got to the facility and mom was in an ambulance,” Walley recalled. “Nobody
from the facility came out and talked to us. Nobody from Emeritus ever came to
the hospital. They never walked out the door.”

The
family filed a lawsuit against the company, alleging negligence in Fall’s
death. Thecase recently settled on confidential terms.. 

In
an interview, Budgie Amparo, the executive vice president for quality and risk
management for Emeritus, expressed
regret for the incident, but contended the company was not negligent in Fall’s
death.

“In
terms of our staff, what we did obviously was to conduct an immediate investigation
as to how this occurred,” Amparo said. “We had staff who was watching her all
shifts..” 

Wendy
Moran, the facility director at the time of the incident, told investigators that
locks were in place to ensure the window could only open 10 to 12 inches, in compliance with state regulations. Fall,
she said, had forced her way out through the window.

Later, the
nurse in charge of the memory care unit, Maggie Carter, said she did not think Fall
should’ve been admitted because she needed more care than the facility could
provide. She said the company actively pressured facility employees to get more
residents into the building, which may have been one of the reasons Fall was allowed
to move in.

“We
was low on residents,” Carter said. 
The company was “very strict about numbers, that we need to keep up our
numbers….We needed more residents in the building.”

Emeritus
did not respond specifically to Carter’s contention. But in a written response
to ProPublica and PBS “Frontline,” company officials adamantly
disagreed with the allegation that Emeritus pressures employees to admit or
retain residents whose care needs they cannot meet just to meet occupancy
goals.

“ Emeritus needs to maintain a
certain occupancy rate to keep the community operating successfully and the
staff fully employed,” the company said in a written statement. “As a result,
we seek to achieve high occupancy by residents whose care needs match the types
and levels of service we provide.”

After Fall’s
death, regulators with Mississippi’s Department of Health inspected the
facility and instructed the company to move its memory care unit to the ground
floor. They didn’t cite Emeritus for any legal violations in connection
with the fatality.

State
Sanctions: None