Mary Meuse was all set to visit her family on Christmas. Two days later, the 83-year-old resident of Woodbriar Health Center in Wilmington was dead.
A certified nursing assistant using a mechanical lift to move Meuse from her bed to a wheelchair Christmas morning violated a cardinal safety rule, according to a former Woodbriar staffer and a report the nursing home filed with Massachusetts regulators.
Most mechanical lifts require at least two people for safe operation, according to the Food and Drug Administration. But the 21-year-old nursing aide, with no assistance, improperly placed Meuse in the lift, according to the report, and Meuse slipped out, crashed to the ground, and broke both legs.
Meuse, who was on blood-thinning medication for heart problems, was not sent to a hospital until the next day. By then, she was bleeding internally. She died in the hospital Dec. 27.
The Christmas Day accident raises new concerns about the quality of care provided by the company that owns Woodbriar, Synergy Health Centers.
Woodbriar, family-owned before Synergy bought it last March, has not had enough staff since the sale, said two people who worked there in 2015 and who asked to remain anonymous because they still work in the industry and fear professional repercussions.
The nursing home has been cited by state inspectors for a number of problems, including crumbling plaster, cracked tiles, or clogged drains in nearly half of the bedrooms inspected in August, according to federal records.
Those same records show that the wrong urinary catheters were ordered for one patient and that a nurse failed to wash her hands before giving medicine to another patient.
Synergy bought its first Massachusetts nursing home in December 2012, and reports of substandard care — festering pressure sores, medication errors, poor infection control, inadequate training, and short-staffing — have mounted. The company now owns 11 facilities in the state, licensed to care for more than 1,200 residents.
The Globe has previously reported that the New Jersey-based company was able to secure a license for Woodbriar with little scrutiny from regulators. State lawmakers directed the health department in July 2014 to create a more public licensing process, designed to open a window onto a system that had been granting licenses behind closed doors. But the department did not implement that new system until last month, after Synergy had been issued four additional licenses.
Woodbriar, a 142-bed facility in the Merrimack Valley, is one of those four Synergy nursing homes that would have received public scrutiny if the state had moved faster to implement the lawmakers’ wishes.
Synergy declined to answer questions from the Globe about the Christmas Day accident or the nursing home’s policy regarding use of mechanical lifts.
In a statement, Synergy said it is “deeply saddened by the passing of one of our residents and expresses our condolences to the family and loved ones.” The company said it investigated the accident and submitted a report to the state health department, which regulates nursing homes.
It also said that problems at the company’s nursing homes reported during the past year by the Globe are “rare and isolated incidents,” and that the company provides “high-quality care with above-average staffing.”
Synergy’s report to the health department states that Woodbriar suspended the nursing assistant pending an investigation. It said Woodbriar also evaluated all of the mechanical lifts used to move patients, reviewed its policy regarding use of such lifts, and conducted a “facility-wide education” on the use of the lifts.
Meuse’s death certificate states she died from “complications of blunt force trauma” and pointed out that she was on blood-thinning medications for heart problems. The certificate noted that Meuse died as a direct result of her injuries.
Meuse’s daughter, Brenda Murray, said her younger sister, Sandra, visited the nursing home late Christmas afternoon and was assured by a staffer that X-rays taken after the accident showed no broken bones.
“We were told everything was OK,” Murray said.
It wasn’t until her phone rang at 8 a.m. the next day that she was told by a nursing home worker Meuse was in considerable pain and needed to go to the hospital immediately, Murray said.
“We didn’t find out her legs were broken until we got to the hospital,” Murray said.
Meuse, a retired nurse who once cared for nursing home residents, hadn’t wanted to create a fuss for her family on Christmas. A vibrant woman who loved all sorts of animals — she had a pet iguana in her assisted living apartment — Meuse said she didn’t want to be hospitalized on Christmas. On that point, Meuse’s family and the report Woodbriar submitted to state regulators agree.
Woodbriar’s report does not include a precise timeline of the events. It does, however, note that shortly after the accident, Woodbriar staff “advised” Meuse’s 22-year-old granddaughter, who was waiting to take her grandmother home for Christmas, that Meuse should be taken to the hospital for evaluation. The report notes that a staffer repeated the recommendation for hospitalization when the granddaughter called Murray to report what happened but says “all agreed with the resident’s wishes, and decided to remain at the facility.”
The report also indicates that the nursing home did not take X-rays until some time after the decision was made to not hospitalize Meuse on Christmas.
The nursing assistant who operated the lift alone, Jocelyn McCoy, has since been fired, said her father, Michael McCoy. He said his daughter, who turned 21 in November, had been working at Woodbriar for only a few months. State licensing records show she received her nursing assistant license in August.
McCoy said his daughter was working on Christmas because Woodbriar was short-staffed that day. He said she worked Christmas Eve, then received a call later that evening asking her to work Christmas, too.
McCoy said his daughter was devastated by the accident, which occurred at 11:30 a.m. Christmas Day. But he said the nursing home was so desperate for staff, the young nursing assistant was asked to not only complete her shift, which didn’t end until 3 p.m., but also to work another entire shift, until 11 p.m.
The father said his daughter was too traumatized and left at 3 p.m.
He also said his daughter was asked to care for 10 patients that day, when a normal shift would be eight or fewer.
“Our hearts go out to the Meuse family,” McCoy said. “This is a tragedy.”
State health department spokesman Scott Zoback declined to comment on Meuse’s death, citing an ongoing state investigation.
Serious injuries and deaths from falls in nursing homes are not unique to Synergy-owned facilities. The US Centers for Disease Control and Prevention reports about 1,800 deaths every year involving nursing home residents who fell.
But Woodbriar stands out, with nearly twice the state and national averages for the percent of falls resulting in major injuries among long-term residents, according to the latest data from the federal Centers for Medicare & Medicaid Services.
The numbers show that 5.9 percent of Woodbriar’s residents had a fall resulting in major injury, compared to 3 percent of nursing home residents statewide, between Oct. 1, 2014, and June 30, 2015. Synergy owned the nursing home during the final four months of that nine-month period.
“This is concerning,” said Tiffanie Haemer, a registered nurse and nursing home specialist at Robson Forensic, a Pennsylvania company that conducts health care-related forensic investigations and analysis. Haemer reviewed federal health data for Woodbriar at the Globe’s request.
The federal data rates a nursing home on the total hours worked by all of its nurses in the two weeks before its last inspection, and on this measure Woodbriar rates above average. But the data also show that the nursing home is “well below” the average for the number of hours worked by registered nurses, which can lead to issues regarding leadership and decision-making, Haemer said. Registered nurses receive substantially more training and education than other nurses and are generally expected to do more critical thinking on the job.
“Additionally, [Woodbriar is] below the national and state average for nurse-aide hours,” Haemer said. “This is concerning as nurse aides provide the hands-on support for most nursing homes.”
It was a nursing assistant, working alone, who dropped Meuse from the mechanical lift. Haemer said most manufacturers require at least two workers to operate a mechanical lift — one to ensure the resident is safely secured in the sling-style machine, while the other operates the controls.
David Hoey, a North Reading attorney who successfully sued a Brockton nursing home for seriously injuring a patient in a mechanical lift in 2005, has been hired by Meuse’s family. Hoey said that, roughly a week before Meuse’s Christmas Day accident, another woman was injured at Woodbriar in a mechanical lift accident, and he has consulted with her family about that incident.
The 89-year-old woman in the Dec. 16 accident survived, he said.