Dan Shively had been a financial institution president who constructed floats for July Fourth parades in Cody, Wyoming, and adored fly-fishing along with his sons. Jeffrey Dowd had been an auto mechanic who ran a canine rescue and hosted a Sunday blues radio present in Santa Fe.
By the time their lives intersected at Canyon Creek Memory Care Community in Billings, Montana, each have been deep within the grips of dementia and exhibiting among the illness’s horrible traits.
Shively had been wandering misplaced in his neighborhood, having outbursts at dwelling, and leaving the gasoline range on. Dowd beforehand had been hospitalized for being confused, suicidal, and agitated, medical information filed in U.S. District Court in Billings present. When Dowd entered Canyon Creek, managers warned staff in a word later filed in courtroom that he might be “physically/verbally abusive when frustrated.”
On Shively’s fourth day at Canyon Creek, carrying a knife and fork, he walked over to a eating room desk the place Dowd was sitting. Dowd informed Shively to maintain the knife away from his espresso, in keeping with a witness assertion filed in courtroom. Shively, who at 5-foot-2 and 125 kilos was half Dowd’s weight and 10 inches shorter, turned to stroll away, however Dowd stood up and shoved Shively so onerous that when he hit the ground, his cranium fractured and mind hemorrhaged, in keeping with a lawsuit his household filed towards Canyon Creek.
“The doctor said there’s not much they could do about it,” his son Casey Shively mentioned in an interview.
Dan Shively died 5 days later at age 73.
Police didn’t cost Dowd, then 66. He stayed at Canyon Creek for almost three extra years, throughout which era he repeatedly clashed with residents, generally hitting male residents and groping feminine ones, in keeping with facility information filed within the courtroom case. His anger would flare shortly. “I’m literally scared to death of Jeff,” one nurse wrote in a filed assertion describing Dowd’s dispute with one other resident.
In courtroom, Canyon Creek denied legal responsibility for Shively’s demise. Its privately held company proprietor, Koelsch Communities, declined to reply questions from KFF Health News. Chase Salyers, Koelsch’s director of promoting, mentioned in an electronic mail to KFF Health News that the corporate prioritizes “the health, well-being, safety, and security of our residents.”
Dowd’s family members mentioned in an announcement through textual content they might not remark as a result of they’d no firsthand information. “We were very pleased with the care Jeffrey received at Canyon Creek,” they added. Dowd was not named within the lawsuit and his present whereabouts couldn’t be decided.
Violent altercations between residents in long-term care services are alarmingly frequent. Across the nation, residents in nursing properties or assisted dwelling facilities have been killed by different residents who weaponized a bedrail, shoved pillow stuffing into an individual’s mouth, or removed an oxygen mask.
A recent study in JAMA Network Open of 14 New York assisted dwelling properties discovered that, inside one month, 15% of residents skilled verbal, bodily, or sexual resident-on-resident aggression. Another research discovered almost 8% of assisted living residents engaged in bodily aggression or abuse towards residents or workers members inside one month. Dementia residents are especially likely to be concerned in altercations as a result of the disease damages the elements of the mind affecting reminiscence, language, reasoning, and social conduct.
More than 900,000 people with Alzheimer’s or different kinds of dementia reside in nursing properties and assisted dwelling facilities. Many of essentially the most significantly impaired stay within the roughly 5,000 services with locked dementia flooring or wings or the three,300 properties devoted completely to reminiscence care. These locations are principally for-profit and sometimes cost 1000’s of {dollars} further a month, promising experience within the illness and a secure surroundings.
Clashes will be spontaneous and too unpredictable to stop. But the possibility of an altercation will increase when reminiscence care properties admit and retain residents they’ll’t handle, in keeping with a KFF Health News examination of inspection and courtroom information and interviews with researchers. Homes which have too few staffers or nonexistent or perfunctory coaching for workers have a tougher time heading off resident conflicts. Homes additionally might fail to correctly assess incoming residents or might preserve them regardless of demonstrated threats to others.
“As much as long-term care providers in general do their best to provide competent, high-quality care, there is a real problem with endemic violence,” mentioned Karl Pillemer, a gerontologist at Cornell University and lead creator of the JAMA research.
“There needs to be much more of an effort to single out verbal and physical aggression that occurs in long-term care,” he mentioned, “and begin to create a model of violence-free zones in the same way we have violence-free zones in the schools.”
Casey Shively holds a photograph of a household ski journey along with his father, Dan, and his sister, Katie, in 1996.(Jessica Plance for KFF Health News; snowboarding picture by Crystal Images Photography)
A Danger to Others
The first indicators of Shively’s vascular dementia emerged in 2011 as confusion, however the illness accelerated in 2016, in keeping with interviews along with his spouse and youngsters and his medical information. He started referring to mountains he knew nicely by the mistaken title and forgot find out how to tie flies on his fishing line. “The decline was so slow at first we thought we could manage,” his spouse, Tana Shively, mentioned in an interview earlier than her death this 12 months.
As the illness progressed, his outbursts grew to become onerous to deal with. He took a swing at one in every of his sons when upset in regards to the temperature in the home. He refused to swallow his medicines and fell repeatedly.
“He would start walking the neighborhood and get lost,” Casey mentioned. “He would turn on the gas stove but not light the stove, and the room would start filling up with gas. He would put clothing in strange places. I found socks in a punch bowl. It got to the point where we couldn’t do this anymore.”
Dowd, in the meantime, had lived in a Santa Fe nursing dwelling and had an extended historical past of dementia with behavioral points, main depressive dysfunction with psychotic options, and hypertension, in keeping with medical information filed in courtroom. Dowd entered Canyon Creek in October 2018 to be nearer to his brother, who lived close by in Wyoming, in keeping with an admission discover the power supplied to staff that was included within the courtroom document. The discover mentioned Dowd suffered from dementia caused by excessive and long-term alcohol use.
Two months later, Shively moved in.
Montana licenses Canyon Creek, which has 67 beds, as a Level C assisted dwelling facility, which allows it to deal with individuals with cognitive impairments so extreme that they can’t specific their wants or make fundamental care selections. Montana law says these services can’t admit or retain a resident who’s “a danger to self or others.”
In the lawsuit, Shively’s household argued that, on condition that regulation, Canyon Creek by no means ought to have accepted or stored Dowd. The Shively household’s lawyer, Torger Oaas, famous in courtroom papers that Canyon Creek’s consumption evaluation kind for Dowd categorized his conduct as “physically and/or verbally abusive/aggressive 1x per month.” Oaas additionally wrote in courtroom papers that in Dowd’s first weeks at Canyon Creek, he mocked and threatened to hit different residents and threw somebody’s silverware to the bottom throughout dinner.
In its protection filings within the lawsuit, Canyon Creek mentioned the Montana statute was too broad to be the premise of a negligence declare and argued that each one reminiscence care residents are unpredictable. And whereas Dowd had yelled and cursed at different residents at Canyon Creek, he hadn’t had bodily confrontations — or any conflicts with Shively, Canyon Creek mentioned. “The accident was not reasonably foreseeable,” Canyon Creek argued.
In the times after Shively’s fall, nurses famous that Dowd was “more anxious, angry toward others.” Dowd yelled at a nurse to get off the telephone and “do your job,” a nurse wrote in a logbook entry filed in courtroom.
“He got into my face,” the nurse wrote. “It looked like he was going to hit me — he had his hand/fist raised.”
‘As Bad as I’ve Ever Seen It’
People with dementia will lash out as a result of they now not have social inhibitions or as a result of it’s the one manner they’ll specific ache, discomfort, worry, disagreement, or nervousness. Some common triggers — overstimulation from loud noises, a frenzied ambiance, unfamiliar faces — are hallmarks of dementia care establishments.
“We can’t expect someone who is constantly and unfailingly disoriented to adapt to our environment anymore,” mentioned Tracy Wharton, a licensed scientific social employee and dementia researcher in Florida. “We have to adapt to them.”
Eilon Caspi, a University of Connecticut researcher, analyzed 105 deadly incidents involving dementia residents and located 44% have been deadly falls during which one resident pushed one other. “Some people are aggressive, and some are violent,” Caspi mentioned, “but if you look closely, the vast majority are doing their best while living with a serious brain disease.”
Jeffrey Dowd stayed at Canyon Creek for roughly three years, throughout which era he repeatedly clashed with residents, generally hitting male residents and groping feminine ones, in keeping with facility information filed within the courtroom case. (Jessica Plance for KFF Health News)
Holly Harmon, a senior vp on the American Health Care Association/National Center for Assisted Living, an business commerce group, mentioned in a written assertion that conflicts can’t at all times be averted regardless of facility operators’ greatest efforts. “If they do occur,” she mentioned, “providers respond promptly with interventions to protect the residents and staff and prevent future occurrences.”
But Richard Mollot, government director of the Long Term Care Community Coalition, a resident advocacy group, mentioned many operators of assisted dwelling facilities, together with reminiscence care models, are pushed by the underside line. “The issue that we see quite often is that assisted living retains people they should not,” Mollot mentioned. “They don’t have the staffing or the competency or the structure to provide safe care.” Conversely, he mentioned, when services have sufficient rooms stuffed with paying clients, they’re extra prone to evict residents who require an excessive amount of consideration.
“They will kick them out if they’re too cumbersome,” Mollot mentioned.
Teepa Snow, an occupational therapist who based Positive Approach to Care, an organization that trains dementia caregivers, famous that the area inside many services, with double rooms, tight frequent areas, and restricted outside entry, can gasoline conflicts. She mentioned the pandemic degraded circumstances in long-term care, as dementia residents with restricted social abilities atrophied in isolation of their rooms and staffing grew even sparser.
“It’s as bad as I’ve ever seen it,” she mentioned.
‘Very Common Fits of Rage’
The following account of Dowd’s time at Canyon Creek relies on 44 pages of nurse’s notes, witness statements, and inner resident-on-resident altercation reviews; all have been contained within the facility’s information and filed as displays within the courtroom case. After Shively’s demise in December 2018, Dowd was given new prescriptions, though the courtroom document is unclear if the change was due to Shively’s demise. Still, the information present, Canyon Creek was unable to move off recurring altercations involving Dowd.
Some have been verbal threats. Once, Dowd yelled at residents in the lounge to close up, referred to as them “retards” and informed them they need to all die, a caregiver wrote in a witness assertion. He grabbed one resident’s face and threatened to kill him, in keeping with a nurse’s word. Another time, Dowd went as much as a resident sitting on a settee and grabbed his walker. Dowd shook it and informed him to close up. According to a witness assertion, as a nurse took the resident to the lavatory, Dowd muttered beneath his breath: “Stuff his head in the toilet.”
Other conflicts have been bodily. Dowd shoved a resident “down on his back so hard his head bounced off the floor,” a nurse recorded in a word. In a special incident reported by a nurse, Dowd pushed a resident who had been agitated and cursing right into a chair. On separate events, Dowd hit two residents on the pinnacle, as soon as inflicting bleeding, in keeping with two resident altercation reviews.
The notes element that Dowd was not at all times the initiator. Once, Dowd’s roommate scratched and punched him after Dowd informed him to make use of the bathroom relatively than pee on the ground, leading to a battle. Caregivers separated the 2. Another day, a resident named Bill wandered into Dowd’s room and pulled Dowd’s hair and beard. Dowd informed the nurses he “felt unsafe and VERY angry,” a nurse’s word mentioned. The nurse led Bill out of Dowd’s room, however Dowd adopted, yelling at Bill that he was “a fat bastard” and saying he was going to make Bill’s spouse a widow.
“Jeff kept making a closed fist as tho he was going to hit Bill,” the nurse wrote in a witness assertion. “I was legit scared because there was nothing I could do to defuse the situation. I’m literally scared to death of Jeff. I’m scared to approach him and talk to him when he gets into these very common fits of rage.”
Dowd in the end went again to his room and a employee locked his door so no different resident would go in.
The information describe how Canyon Creek caregivers intervened after altercations started, usually separating the preventing residents and updating Dowd’s brother on the clashes. Nurses would take away Dowd or the opposite resident from a room and discourage such acts. “Tried to explain it was inappropriate to hurt others,” one nurse wrote after one incident.
Salyers, the corporate advertising and marketing director, mentioned in his electronic mail that the employees at Canyon Creek and different Koelsch services are “highly qualified” and “extensively trained.” He mentioned the corporate’s reminiscence care communities are “distinctively designed and staffed” for individuals with Alzheimer’s and different types of dementia.
‘It’s Nice To Have a Girlfriend’
The nursing notes and statements within the courtroom file counsel that incidents have been frequent sufficient that nurses commented on Dowd’s occasional serenity. “No agitated or aggressive behaviors this shift,” one word mentioned. Another nurse word mentioned Dowd “continues to isolate at meals, sitting at a table by himself.” While Dowd loved studying books and doing puzzles, he was overheard saying he was depressed and was “wondering if he wouldn’t be better off if he wasn’t around anymore.”
Nurses famous Dowd repeatedly exhibited sexual conduct that was both inappropriate — making “crude oral gestures while looking at younger females” — or ambiguous, reminiscent of inserting his hand on a resident’s shoulder and commenting, “It’s nice to have a girlfriend.” Someone noticed Dowd “grabbing on multiple residents[’] private areas,” a witness assertion mentioned. When nurses caught the conduct, they separated these concerned and rebuked Dowd. A workers member wrote in an announcement that Dowd was inappropriate all through her shift, making sexual jokes and “trying to grab me.”
According to nursing notes, in summer season 2021, Dowd informed one feminine resident he needed to see her genitals and later touched her breast. In August, a caregiver walked into Dowd’s room and located him touching the identical resident beneath her shirt and pants. The caregiver informed Dowd to “stop it and not ever do that again” and introduced the lady out to fulfill her household, who had come to go to her.
After that incident, Canyon Creek despatched Dowd to the emergency room at Montana State Hospital, a public psychiatric facility, in keeping with a nurse administrator’s testimony in a deposition filed in courtroom. The nurse testified Dowd was now not at Canyon Creek. That is the final point out of Dowd’s whereabouts within the public document. A spokesperson for the Montana Department of Public Health and Human Services, which oversees the hospital, wouldn’t affirm whether or not he was a affected person.
At a pretrial listening to, the decide excluded dialogue about Dowd’s altercations after Shively’s demise. In a courtroom submitting, Shively’s lawyer requested permission to share proof with the jury that Canyon Creek gave its government director a bonus any month when 90% or extra of the beds have been crammed so he might argue Canyon Creek had a monetary motivation to confess Dowd. But the decide additionally barred that info from the trial, which Canyon Creek mentioned in a courtroom submitting was irrelevant.
The Shively case went to trial in 2022 earlier than a federal civil jury in Billings. Despite the exclusions, the jury determined Canyon Creek’s negligence triggered Shively’s demise. It awarded the household $310,000.
“For us, the money wasn’t a huge factor,” mentioned Spencer Shively, one other of Dan Shively’s sons, who referred to as the damages so modest as to be a victory for Canyon Creek or its insurer. “At least they were negligent per se. But I don’t know it really changed anything. For me, I got some closure. I feel like these facilities are just continuing to do the same things they’re going to do because there hasn’t been systemic change.”
Jordan Rau:
[email protected],
@jordanrau
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