More than 100 Minnesotans die each year after suffering falls in nursing homes. Few deaths are fully investigated by the state, and serious penalties for violations are rare.
But at 74, he found his well-ordered life invaded by Parkinson's disease. His limbs trembled and dementia left him wandering and frostbitten. Worried for his safety, Swanson's family made the difficult decision thousands of Minnesota families make each year: He needed to be in a nursing home. In 2005, they moved him to Crest View Lutheran Home in Columbia Heights.
There the staff observed "dangerous" behavior by Swanson, noting it in his chart. One night a nurse found him standing on his bed. Another night, he was discovered crawling around on the mattress. Nine days after that, a nurse found him on the floor by his bed. Swanson had fallen and his hip was broken.
Three days later, he died.
Swanson is among more than 1,000 Minnesotans whose deaths were related to falls in nursing homes from 2002 through 2008, according to a Star Tribune analysis of death certificates. On average, one nursing home resident in the state dies every two days in circumstances stemming from a fall. The nursing home industry has tried to remedy the problem, but so far there are no signs that its efforts or any state actions are significantly reducing the number of deaths.
Less than 10 percent of fall-related deaths in nursing homes are fully investigated by the Minnesota Department of Health, which is charged with monitoring nursing home care. Usually nursing homes themselves are left to privately probe the cause of fatal falls on their premises. State regulators review those findings, but sometimes don't do more. Even when regulators discover that a mistake led to a resident's death, they often do not cite nursing homes for violations of state and federal regulations.
Minnesotans in nursing homes fell after aides left them alone on toilets and went to tend to other residents. They fell while being transferred -- such as from a bed to a wheelchair -- by one aide when two were needed. They fell when aides misused equipment for moving them and dropped them in the process.
Some died quickly, their fragile neck bones snapped or their aging bodies overwhelmed by internal bleeding caused by the fall and compounded by blood-thinning drugs. Others -- often still enjoying some quality of life -- were suddenly bed-ridden in excruciating pain from broken bones.
In interviews with the Star Tribune, more than a dozen former nursing aides who worked at Minnesota nursing homes that have had fall-related deaths cited staffing problems as a concern. By at least one federal measure, 75 percent of Minnesota nursing homes are understaffed, although both state and federal staffing standards are vague.
Minnesota ranks third highest in states for falling deaths in those 65 and older from 1999 to 2006, whether they were in nursing homes or not. After a fall, a spiral of decline often begins in the elderly. Weakened by the ordeal, victims succumb to pneumonia or see their chronic health conditions erupt with a vengeance. The fall, medical experts say, sets off a deadly systemic chain reaction, hastening the end of life. It's a growing concern as the U.S. population ages, setting the stage for more falls, more pain, more untimely deaths.
"I think if you asked a person on the street, not one of them would know that if you take the frequency of falling and the consequences of falling, it's as big a problem as heart attacks and strokes," said Dr. Mary Tinetti, a Yale University medical professor who studies falls.
Hospital bills to treat the elderly for falls totaled more than $1.1 billion in Minnesota between 1998 and 2005, according to the state Health Department.
Advocates for the elderly say if more of the deaths related to falls were subject to a more rigorous regulatory microscope, it would reveal both overburdened staffs and mismanagement. But Minnesota's system leaves scant public record of how many falls were avoidable and how they could have been prevented.
At risk of falling
Swanson's family knew that the fall and injury caused his sudden decline. What they didn't know until recently -- four years after he died -- was that a state investigation later determined that despite warning signs, the staff at Crest View didn't take the necessary steps to keep Swanson safe from falling.
When Swanson arrived at Crest View, the staff considered him a fall risk, according to a state investigative report. He was blind in one eye from a previous accident and had an unsteady gait. They put alarms on his bed and wheelchair so the staff would hear if he tried to get up on his own. They gave him a concave mattress and a bed that lowered almost to the floor.
But Swanson regained strength through a month of physical therapy, so the staff took off the alarms. Though the nurse saw him scrambling atop his bed later, the alarms were never put back. State investigators found that Crest View's staff should have reassessed his safety needs.
The law prohibits discussing specific cases, said Crest View Chief Executive Officer Shirley Barnes, in a written statement to the Star Tribune. The nursing home investigated falls, cooperated with the Health Department and, when needed, took corrective action, conducted training and changed procedures, she wrote, adding that the facility continues to make progress in the area of falls. Barnes said in an interview that Crest View has tried a number of strategies for calming agitated patients who don't sleep well and might get up during the night and fall, including aromatherapy, drum circles and soothing music.
Swanson's daughter and ex-wife said they never knew about his behaviors before he died, nor did they know about the investigation or report made public without Swanson's name on a Health Department website.
His family says his care at Crest View nursing home cost more than $4,000 a month.
"What bothers me is that they never told me that he was doing this," his daughter Becky Beaudette said while reading the state report for the first time, when it was provided by the Star Tribune in August. "We would have done something if we knew he was doing all this other stuff at night."
Responding to Star Tribune questions, state regulatory officials said in September that they had reiterated to investigators the importance of calling families in such cases.
During its investigation at Crest View, the state found additional problems with falls there. In a single month -- April 2005 -- there were 48 falls involving 33 residents at the facility, the report shows. Although the facility "identified a concern" with an increased number of falls, it didn't revise its fall-prevention program, the report said.
The state cited Crest View for flawed care, concluding that it violated three federal regulations. Under standard procedure, Crest View was given time to correct the deficiencies and avoid punishment, which can include withholding Medicare and Medicaid payments, and stripping the home of certification. Those issues were addressed and regulators took no further action.
Efforts at prevention
The nursing home industry says the realities of working with a frail population mean that not all fall-related deaths can be prevented.
But over the past few years, some nursing homes have launched fall-reduction efforts, using sophisticated equipment to pinpoint balance and gait weaknesses, providing strength training and beefing up internal investigations. They say they are doing all they can to prevent serious injuries and deaths from falls.
"I don't think you'll find anybody in the industry that says we don't need to do a better job in preventing falls," said Darrell Shreve, vice president of health policy at Aging Services of Minnesota, an industry group representing mostly nonprofit nursing homes. "That's why we've got people working on that."
Over the past two decades, changes in laws and a shift in nursing home philosophy aimed at increasing the dignity of the elderly made it even harder to prevent falls. An emphasis was placed on promoting more freedom for residents and less use of restraints, hoping patients would feel healthier and stronger. Most acknowledge it is a strategy with risks.
"There's a lot of misery that comes with the restrictions to prevent ... falling," said Dr. Robert Kane, director of the University of Minnesota's Center on Aging. "Nobody is in favor of people falling. But on the other hand, we can be so overly restrictive that we ... take away the quality of their lives."
Use of restraints has been vastly reduced for the more than 30,800 residents of Minnesota's 397 nursing homes. That has made fall prevention "the next thing on our list," said Dr. John Mielke, medical director of North Ridge Care Center in New Hope. "How do we keep people as safe as possible with as few restraints as possible?"
Under federal rules, every nursing home resident must be assessed for fall risk. Over the past two years, small consortiums of Minnesota nursing homes have made fall-prevention a priority. Under a state incentive program, some get extra payments to improve their performance. One group, Empira, received $4.2 million last year for 16 participating nursing homes.
Part of Empira's strategy is changing how the homes try to prevent falls. Some homes are improving their investigations into what causes a particular resident to fall. A few turn to technology: St. Therese Home in New Hope bought expensive diagnostic equipment to pinpoint weaknesses when residents sit, stand and move.
"Falls are an issue for ... every housing setting that has elderly clients," said Denise Barnett, administrator at St. Therese. "As we age ... we lose so much muscle mass... we lose so much ability to balance."
Families should expect greater safety in nursing homes than in independent living, industry officials say, but there isn't money for one-on-one care. Trying to eliminate falls is unrealistic, they say.
"I think families should expect a lot out of us," Mielke said. North Ridge, the state's largest nursing home, had 47 fall-related deaths from 2002 through 2008. "At the same time, I would like them to be well-informed enough ... that they can accept what happens in spite of all of our best efforts."
Unraveling the cause
At St. Therese, in the midst of a heightened effort to prevent falls, a paralyzed, high-profile resident died after he was dropped as two nursing aides moved him from a wheelchair to bed last spring.
The Rev. Tim Vakoc, a 49-year-old Roman Catholic priest and Army chaplain, had suffered a devastating head injury in 2004 from a roadside bomb in Iraq. His convalescence was chronicled by the Star Tribune. On June 20, he died after falling to the floor and injuring his head, a state report determined.
The state's investigation found no neglect by St. Therese nursing home, but blamed the two nursing assistants, saying they gave "incongruous" explanations of what happened as they tried to move Vakoc using an EZ Lift device. The nursing assistants no longer work at the home. Since 2004, at least 17 nursing home residents died or were injured across the state after being dropped from lifts.
"You have to always keep in mind that it's humans caring for humans," said Barnett of St. Therese. "It doesn't matter where you are, you will have mistakes ... that's real life."
When someone alleges that a fall was due to maltreatment or neglect, the state Office of Health Facility Complaints decides whether to investigate.
But those investigations do not always happen swiftly. The office took, on average, 39 days to go into a nursing home after a fall. By then, interviews of those involved often failed to yield clear answers, and allegations could not be resolved.
Some families, such as Swanson's, don't learn of the full circumstances surrounding their loved one's fall and subsequent death, even when there is an investigation. Many families never file formal complaints, which often leaves the state relying on the nursing homes themselves to report falls.
After a long, sad decline in a relative's health, family members are sometimes relieved the pain has ended, and are reluctant to ask questions that might have disturbing answers.
A family files a complaint
Jeanette Lashinski doubts she ever would have filed a complaint about her mother's fall-related death in 2006. But her sister-in law, who worked in nursing home business offices much of her career, decided it was important to pursue.
Lashinski's mother, Alice Kalas, was active into her late 70s, going dancing three times a week. But Lashinski said her mother's back started hurting and the longtime seamstress learned she had scoliosis. It affected her balance.
With arthritis and dementia, Kalas went to live at the Camilia Rose Care Center in Coon Rapids in early 2005. Nearly a year later, a nursing aide helped her to the bathroom and went across the hall to make a bed, according to a state investigative report.
As the aide returned, she heard a crash and saw Kalas on the floor, head down. An X-ray scan showed her neck was broken. Kalas, 81, developed pneumonia and died 20 days later.
A state probe faulted the nursing home. Kalas had a history of falls, the investigator found, citing four in the previous 10 months. The home failed to provide "supervision, assistance and on-going interventions" to reduce her risk, the state found. An alarm the staff had put on Kalas was removed with family'agreement because it agitated Kalas. Once it was removed, charts didn't list her as a fall risk anymore, and the staff thought it was safe to leave her alone in the bathroom.
Lashinski, caring for her cancer-stricken husband while her mother was in the nursing home, couldn't tend to both. She still feels guilt for putting her mother there.
"I thought that we were going to keep her from the kind of death she had," Lashinski said.
Her sister-in-law, Helen Kalas, called the Health Department days after her mother-in-law's funeral. "If you don't complain," she said, "how can you allow this to happen to ... other elderly people coming in?"
The state cited the nursing home for failing to prevent the accident. The home corrected its deficiencies and no fines were issued. The family settled a lawsuit with the nursing home in 2007. Camilia Rose referred questions to Mielke, who is also the home's medical director. He declined to comment on the case.
Sorting through what led to a fall can be confounding.
Tania Rubin, 93, survived the Nazi advance in the Soviet Union, but a fall at Texas Terrace Care Center in St. Louis Park made her last days painful, her family said.
Documents provided by the family's attorney say Rubin had been in the hospital with respiratory problems and chest pain, and went back to the nursing home on April 1. The staff put an air mattress on her bed. There is a question about whether her family and doctor or the nursing home ordered it. Her family says it was slippery and unsafe.
Granddaughter Niza Schear said they talked with the staff about it before going home that night. They also asked for bed rails, daughter Klaudia Przetycki said. A nursing home report says the family and doctor ordered the mattress for Rubin's comfort and the nursing home warned against it because of an increased fall risk.
Nursing home administrator Mathew Bedard said he couldn't discuss specific cases, but said all specialty surfaces are physician-ordered and there are special regulations for bed rails. He said Texas Terrace takes many precautions to lower fall risk.
Early the next morning, the staff found Rubin bleeding after hitting her face on an oxygen tank near her bed. She died a week later.
The family's lawyer, Kenneth LaBore, said "it's those situations where someone has a change in condition ... that you have to reassess ... the safety interventions for people." The home, he said, knew Rubin's condition had changed.
A hospital report after the fall said Rubin was suffering and dying, her chronic medical conditions no longer treatable. It is unclear whether a complaint was ever made to the state. A death certificate shows Rubin died of congestive heart failure, aortic stenosis and other natural causes. It does not mention her fall.
But Przetycki said seeing her mother blue-faced and suffering was painful.
"I got sick ... myself from this," she said, sobbing.
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