Inept boss, altered records, ignored warnings at Pa. vets' nursing home with 38 COVID deaths
By WILLIAM BENDER | The Philadelphia Inquirer | Published: May 30, 2020
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(Tribune News Service) -- As the coronavirus pandemic bore down on the Philadelphia region, nurses and other frontline health-care staff at the Southeastern Veterans' Center were alarmed.
Commandant Rohan Blackwood, head of the state-run nursing home in Chester County, and his top team seemingly adopted a wait-and-see strategy to combat the scourge.
Despite a state Department of Health advisory in mid-March telling care facilities to end communal dining if the coronavirus was spreading in their region, residents in the 238-bed veterans' center were still eating in dining halls.
The risky practice continued through the first week of April -- even though the highly contagious COVID-19 was already confirmed to be inside the building. By April 8, one resident had died of the virus and 13 staff and residents had tested positive, according to an internal report.
For weeks, supervisors had actively discouraged nurses and aides from wearing masks, including telling a staffer not to do so because it might frighten the service veterans, the staffer said.
Later, the protective N95 masks were distributed to administrators and others working in private offices, while many nurses and aides, at first, were equipped with less protective surgical masks.
By mid-April, residents were dying rapidly -- as many as four in one day -- as the coronavirus tore through the home, infecting more than 110 people inside.
At least 38 residents there have died of COVID-19, according to the Chester County coroner. This makes the home an extreme outlier within the Department of Military and Veterans Affairs' network of six nursing homes. The state's five other homes, including one in Philadelphia, have kept the virus at bay, with about 15 infections and fewer than five deaths among them, according to the state Department of Health.
How could that be?
Although the insidious new virus can infect even the best nursing homes -- where fragile older adults share air, space, and food in close quarters -- leadership and best practices can mean the difference between weathering a crisis and being consumed by it.
Interviews with 17 current and former employees at the Southeastern Veterans' Center, as well as with residents' families and union officials, paint a picture of a nursing home that not only responded slowly to the pandemic but that has been mismanaged for years by top officials, including Blackwood, known as an autocratic leader who retaliates against those who question his decisions.
Staff members who spoke to The Inquirer described chronic understaffing -- which studies have linked to infectious outbreaks -- as well as the altering of medical records to conceal that and other shortcomings.
"It's horrible how that place is being managed," said Ian Horowitz, whose 81-year-old father, Ed, died this month of complications of the coronavirus.
Before Ed Horowitz -- an Army vet and onetime Philly cop and Rittenhouse Square bar owner -- contracted the virus, his son had asked SEVC staff why his father was living with a sick roommate, presumed to be positive for COVID-19, and what steps the facility was taking to protect him from getting infected. He didn't get answers.
Days later, his father told him that men in hazmat suits had come in and transported his roommate to the hospital. Both men later died within 10 days of each other.
"It's [the same] story after story from families," Horowitz said. "They couldn't get any information out of the facility about how their relatives were being treated."
Horowitz was among the earliest of a growing number of families and elected officials who called for an investigation into how SEVC handled the coronavirus crisis -- one now underway.
On Tuesday, Blackwood and another senior official, nursing director Deborah Mullane, were suspended indefinitely amid an investigation into the center's operations. Barbara Raymond, head of another state-run veterans' home, was appointed acting commandant.
The state Bureau of Veterans Homes has been investigating complaints made in April about working conditions at SEVC, but employees did not want to be seen talking to an investigator, fearing Blackwood would punish them. The interviews had to be relocated, according to Tom Tosti, an officer of the union representing licensed practical nurses, nurse's aides, and other SEVC employees.
"The members felt intimidated, and they knew Rohan would have been watching them going into that interview process," said Tosti, district council director for the AFSCME union.
Some family members of veterans said they, too, were reluctant to go against Blackwood.
Frederika Rivera-Torres said that during Blackwood's first year as commandant, she challenged him about medical orders and decisions regarding her veteran husband's care.
"I'm the concerned wife and medical power of attorney," she said in an interview. "I have a right to know what these orders are."
Rivera-Torres followed up with the state Department of Health, she said, only to be surprised by a January 2016 letter from an SEVC lawyer informing her that the "commandant has the authority to bar you from the facility."
She stopped being as vocal, she said, worried that Blackwood might block her from visiting. Her husband died six months after the letter.
"There are good, kind people who work there, but there are other people who are in it for the job," she said. "And they bring their personalities with them."
Blackwood declined to answer questions about why his facility accounted for at least 90% of the coronavirus deaths among the state's six veterans' homes, or reply to a detailed list of questions.
Joan Nissley, a DMVA spokesperson, said in a statement: "The SEVC has taken every precaution to protect its residents and staff. ... The SEVC also recently passed a PA Dept. of Health COVID-specific inspection as well as a remote Chester County Dept. of Health procedural inspection which confirmed the protocols we are using are correct. We continue to be vigilant."
As of Friday evening, she didn't answer a list of specific questions.
In February 2015, Blackwood landed at the sprawling Southeastern Veterans' Center, in East Vincent Township, 35 miles up the Schuylkill from Philadelphia.
Blackwood, 47, who had previously managed other senior care facilities in the region, rose to make $119,453 as a state employee. But after Blackwood and his deputies took over, morale plummeted, several staffers said.
Bruce Grissom, the nursing home's former director of social services, had worked there for 15 years by then. "Oh, my God, I loved it," he said of helping retired veterans.
Two years ago, he resigned, blaming Blackwood's "hostile" management style and what he perceived as a lack of respect for the veterans there.
"He would scream at me. I'm 68 years old, but he treated me like a 5-year-old," Grissom said. "Unfortunately, he treated a lot of people like that."
A longtime nurse at SEVC was so upset with how it was run under the Blackwood regime that she filed a complaint in April with the state Department of Health that detailed what she said was destabilizing staff turnover as well as faulty inspections that failed to uncover deficiencies there.
"The only reason we're still there are the veterans. We don't want to abandon them," said the nurse, who spoke on the condition her name wouldn't be used, fearing retaliation. "They're our heroes, and they don't deserve to be treated this way, and neither do their families."
Blackwood had left behind a trail of lawsuits from a job he held from 2012 to 2014 running the Golden Living Center in Lancaster, part of a national chain. The federal Centers for Medicare & Medicaid Services had put it on a "special focus" list for troubled facilities.
Blackwood was named as a defendant in four lawsuits filed in Lancaster County against the facility, each alleging mistreatment of residents due to staffing shortages there. The goal, the suits claimed, was to maximize profits.
"Knowing that staffing costs were the largest part of their nursing homes' budgets, Defendants chose to operate and/or manage the Facility to maximize their profits at the expense of the care provided to their residents," according to a 2015 lawsuit filed on behalf of a resident. The case was later settled.
Another lawsuit, filed on behalf of a resident who died an "untimely death," accused the Lancaster home of making medication errors, failing to prevent infections, and maintaining "fraudulent documentation" about caring for the resident when she or her caregivers were not even in the facility at the time. That case was also settled.
Separately, the state Office of Attorney General sued the Golden Living chain in 2015 for false advertising and mistreatment of residents at 25 facilities in Pennsylvania, including the one where Blackwood worked. (The chain has since sold it.) The office alleged that Golden Living residents "routinely have to wait hours for food, assistance with toileting, changing of soiled bed linens and other elements of basic care and sometimes must forgo them entirely." The case is ongoing.
Just before going to the Southeastern Veterans' Center, Blackwood worked for 11 months as executive director of the Phoebe Wyncote nursing home in Montgomery County.
The staffing and medical-care problems described in the lawsuits can also be found at Southeastern Veterans' Center, interviews and documents show.
One former nurse said Blackwood's administration, well before the pandemic, repeatedly waited to seek medical treatment for residents who were clearly injured or gravely ill.
"They wouldn't send people out [to the hospital] until they were like half-dead," she said. "I was like, 'Why are you doing this?' It was almost like they thought they're here to die."
She recalled one shift when two residents were "dying in front of my eyes," but said Blackwood's staff still resisted her pleas to have them hospitalized. Both were later found to have serious medical conditions, she said.
In another case, the former nurse said, she could not get approval to hospitalize a resident with a bowel obstruction so severe he looked "like he was 10 months pregnant." When his symptoms became so obvious that they could no longer be ignored, he was rushed to the hospital. "He died that night," the nurse said.
SEVC employees have complained of being pressured by the administration to change medical reports or statements that might reflect negatively on the facility.
In one instance in September 2018, a nurse said she found a resident had been paging an aide for 25 minutes with no answer. The aide, working a night shift, had disconnected the alarm bell so she could sleep. The nurse said she went to submit a written report about the incident, but an assistant director of nursing at SEVC urged her not to do so.
A former department head told The Inquirer it was routine for Blackwood and other administrators to alter staff reports that were required for state inspections. Nurses would collect the paperwork and spend "hours" in an office with a copying machine going through and editing the documentation, the former department head said. When finished, they would contact the original author and return the edited documents.
A nurse said she was explicitly ordered not to tell a state inspector about staffing shortages, or that nurses from other floors had had to come help fill out paperwork at the end of some shifts. Another former nurse said she saw a death certificate being altered so that a resident's fall, which resulted in a broken pelvis, was not listed as a contributing factor to his death.
"I just couldn't believe it," the former nurse said of the changed death certificate. She said her colleagues were also asked to modify their notes to make it appear that residents were healthier and more satisfied with their treatment than they had indicated.
State Sen. Katie Muth, whose district includes SEVC, said she is now deeply skeptical about the home's previous record of high ratings.
Muth said she was told that inspections -- an integral part of the federal five-star rating system for nursing homes -- were tightly controlled at SEVC, with state inspectors steered to speak only with employees who had been selected by Blackwood and his administrators.
"I don't know how you ever get real information about what's going on," Muth said. "It ends up where there's one set of eyes on the place, and arguably it's not independent."
Other accusations include staffers who in 2017 reported that SEVC supervisors had been altering employees' punch-out times. Their union tried to get Blackwood's team to address their wage-theft complaints but got nowhere, said Tosti, the AFSCME leader.
The union turned to the U.S. Department of Labor, which in 2018 found 230 violations and ordered the facility to pay $210,360 in back pay, records show. One staffer received a lump-sum payment of about $6,000 for two years of underpayments.
The allegations of altered documents are not limited to payroll records. In some cases, employees have questioned the official record following adverse events.
When Patrick Donahue wandered out of the center one afternoon in April 2019, his wrist and ankle monitors failed to sound an alarm. Sensors on the lobby doors weren't working, sources familiar with a subsequent investigation said.
Two hours later, a crew member of a production company filming a documentary at the nearby Pennhurst Asylum spotted Donahue on an isolated road, confused and alone in a downpour.
"The road is completely desolate," Geraldine Alvarez, the crew member, said. "Just seeing a man with a walker was the strangest thing I saw that day."
On a hunch, she called the veterans' home, where a staff member told her they had seen Donahue just 30 minutes ago.
"I didn't think that was accurate," Alvarez said. "He walked off a good distance, and he's a slow walker. He was probably there for hours."
Nursing logs indicated that staff had recently checked Donahue's room, and confirmed he was in bed and had received his medicine, a source said. But security staff believed the logs were simply filled in without bed checks. Other residents had also wandered off from the dementia unit, a former staffer said.
Nissley, the DMVA spokesperson, said the nursing home "made enhancements at the facility to prevent any such further incidents."
Families said they sometimes got misleading answers when asking about their relatives inside the Southeastern Veterans' Center.
Karen Williamson said the administration provided shifting explanations about what happened to her father, 79-year-old former Army paratrooper Joseph Conroy, after she made repeated complaints about another resident intruding into Conroy's room. As a remedy, they put a sign on his door that said "Closed."
Williamson was awoken by an early morning phone call in June 2019 telling her that her dad had been taken to Phoenixville Hospital. She said she was told by a nursing home staffer that he fell and hurt himself.
But in surveillance video obtained by The Inquirer, the same resident she had complained about is seen walking into Conroy's room at 10:42 p.m. Two minutes later, both emerge, with Conroy swinging a shoehorn in apparent self-defense. The other man returns to his room, nearby, only to enter Conroy's room an hour later. An argument ensues and spills into the hallway, where the attacker throws Conroy into a wall.
They both fall, then the attacker walks off, leaving Conroy on the floor.
Nursing staff put Conroy back in his room, where he cried out in pain for hours until someone called for an ambulance.
Only after repeated calls to the nursing home did Williamson reach her father's caseworker and learn a full account of the incident, she said. "I felt like they did not protect him when he needed protection."
Conroy underwent hip surgery and died days later back at SEVC.
"I was outraged, I was brokenhearted. He still had a lot of time, I think," Williamson said in an interview, her voice choking.
Nissley, the DMVA spokesperson, declined to comment on Conroy's death.
In a hearing this month by the Senate Democratic Policy Committee on the impact of COVID-19 on nursing homes, Dr. Darryl Jackson, chief medical officer for the DMVA, told Senate committee members that a delay in testing prevented the Chester County vets' center from containing the virus' spread.
Jackson said officials had intended for SEVC staff to be assigned to either COVID or non-COVID units, but a "significant nursing shortage" made that untenable and led to the National Guard's being called in to help.
The SEVC had also planned to use isolation rooms for residents while they awaited test results, Jackson said, but it took days to get them back, and quickly there were too many possible cases.
But, he said, the state was in charge of whom they could test, and for weeks the department was not permitted to seek outside testing. "We weren't in control of the testing," Jackson said. "We've done the best that we could possibly do."
Maj. Gen. Anthony Carelli, who as adjutant general for Pennsylvania oversees the state's six veterans' homes, told the Senate committee that he was concerned by The Inquirer's articles last month about the outbreak at SEVC and asked the state and county to inspect the facility.
He was told they found no discrepancies with the required protocols.
Carrelli acknowledged that, after the deaths and cases mounted at SEVC, he did not press the state to make testing available for all residents and staff members there and at the five other veterans' homes, believing it wouldn't have been "fair."
"To the Department of Health and the governor, they're just six of many," he said. "As far as the state is concerned, every single home is important."
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