81-year-old Dolly Moore gradually became more and more lethargic and eventually lost her appetite.  Yet, nurses at Parklands Rehabilitation & Nursing Center in Gainesville told her children their mother’s worsening dementia triggered the symptoms.  Her lab results were normal, they said, even though the results actually indicated the resident was suffering from a severe infection that had spread throughout her entire body.  The abnormal labs were never reported – a frightening practice that is becoming more common in Florida's nursing homes.  Since a doctor never had an opportunity to treat Moore’s condition, a state investigation found, the infection continued to worsen and eventually take Moore’s life on Oct. 1, 2014.“The hospital told us it was the worst case of neglect they’ve ever seen,” said Connie Thames, Moore’s daughter.Florida’s Department of Children and Families found that Moore died of neglect.  Those findings were subsequently forwarded to Florida’s Agency for Health Care Administration (AHCA), the department that oversees the state’s 687 nursing homes, and is responsible for taking action against offenders.  However, in many case, there is often no evidence AHCA even investigates these deaths.

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“The industry complains about how punitive and horrible the system is and, in reality, almost nothing happens to any of them, no matter how bad the situation,” said Toby Edelman, senior policy attorney with the nonprofit Center for Medicare Advocacy in Connecticut.As part of its investigation, 54 patient deaths verified by the Department of Children and Families as resulting from nursing home neglect or mistreatment from 2013 through 2017 were reviewed.  The deaths were detailed in reports on 43 cases.  The state-verified findings of abuse and neglect by nursing home staff were then sent to AHCA.  Among those cases under review were the deaths included a 91-year-old Sarasota woman who died vomiting fecal matter; an 87-year-old woman in Boynton Beach who lost her life after staff crushed her ribs and punctured her lung; and an 84-year-old Jacksonville man who died from an untreated infection that spread from his rotting genitals.In 32 of 43 cases, the AHCA took no action against the nursing homes after it was determined staff caused or contributed to the deaths.  The agency admits it failed to investigate ten cases, and in 18 others it’s not clear AHCA investigated at all because there were no notes in the patient’s records indicating a follow-up investigation was conducted.  The U.S. Department of Health and Human Service’s Office of Inspector General audit, published in April, found that the AHCA wasn’t even verifying that nursing homes corrected problems when state inspectors cited them.AHCA spokesperson Mallory McManus responded by stating, “We are always working to improve our processes and have identified and initiated changes.  This includes working with DCF to ensure that there is no wrong door for reporting findings related to a nursing home death.”McManus said the agency will continue to improve its coordination and communication with others investigating neglect and abuse cases.  AHCA will implement an independent review of all nursing home deaths verified by the state as neglect or mistreatment and create “a state-level process to address investigation result,” she said.Some say the penalties imposed simple aren’t enough.  Michele Ozkan doesn’t believe a $15,337 fine was sufficient enough for Tarpon Point Nursing and Rehabilitation Center in Sarasota after the 2014 death of her mother, Stella Budich, who passed vomiting her own fecal matter.“They can do what they want to people, cause their deaths, and nothing happens,” Ozkan said. “Somebody has to be held accountable.”

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Neglected: Even when staffs cause patient deaths, Florida nursing homes face few penaltiesFeds: FL inspectors didn't ensure hundreds of problems at nursing homes corrected