After successful surgery to repair the aneurysm, Bothun decided to recuperate for a few days at the Martin Luther Care Center in Bloomington, her husband later said in a deposition. The last thing she told her husband before he left her the night of Jan. 18, 2009 was: “You go home and get a good night’s sleep. I feel good, and I’ll see you tomorrow morning for breakfast.”
It’s unclear exactly what happened next. What is known, according to police, court and Health Department records: The nurse who was directly responsible for Bothun’s care that morning, Meaza Abayneh, told police she went to Bothun’s room at 3 a.m., found that she was short of breath and unable to give a blood pressure reading, according to a Bloomington police report. Abayneh said she tried to give Bothun nitroglycerin. but her patient went unconscious. She said she then called police, because the facility’s 911 system was down.
Mokandu told a different story to a Health Department investigator: He said he was supervising Bothun while Abayneh went on break. He went to Bothun at 3 a.m. when she hit her call light to ask for pain medications, which he gave without providing any medical assessments. Mokandu said that at 4 a.m., Abayneh told him that she wasn’t able to get a blood pressure reading from Bothun. Mokandu said he had Abayneh call the police.
When paramedics arrived at 4:42 a.m., they reported that Bothun’s skin was blue and her legs were mottled, an indication she hadn’t received oxygen and had been in cardiac arrest for at least 20 minutes.
Abayneh’s notes regarding the vital signs she took from Bothun had no times listed when the checks were made. Neither nurse could explain to the officer on the scene why it took at least a half-hour to call police.
The state Health Department found the facility neglected Bothun when Mokandu medicated her without evaluating her condition and that both nurses failed to properly monitor her declining condition, help emergency personnel or initiate CPR.
Mokandu and Abayneh pleaded not guilty to the criminal neglect charges. Prosecutors agreed to dismiss the charges after the nurses served a year of probation and paid $500 in court costs.
The Department of Health and the Nursing Board also learned that Mokandu had previous problems at the facility, including being warned by the home for falsifying records in 2005, failing to ensure skin assessments were being documented and failing to notify a resident’s doctor of an incident where the resident suffered injuries. In April 2010, he gave a discontinued medication to a resident. That month he resigned from the Martin Luther Care Center in lieu of being fired.
Abayneh was suspended for three days from the nursing home following Bothun’s death, then resigned in February 2009.
In his response to the Nursing Board, Mokandu denied that he failed to adequately respond during the Bothun case. He said he provided adequate care to his patients but did not always document the care. A licensed practical nurse since 1998, Mokandu was granted an RN license in July 2009.
Mokandu and Abayneh declined to comment through their attorney, Rebecca Moos. She said the criminal charges and the Health Department’s neglect finding resulted from language differences and a misunderstanding on the part of the Bloomington police.
Bothun’s husband, LeRoy, filed a wrongful-death lawsuit against the nurses and the home. It was dismissed, with a district court and appellate judge ruling that Bothun could not prove the nurses’ care caused his wife’s death.
The Bothuns’ son Robert said the nurses who were supposed to care for his mother that morning should have lost their licenses.
“They shouldn’t be in charge of caring for people,” he said.
Relatives of Firman Adams said they feel the same way about the last nurses assigned to care for him.