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Everyone knew Walter Haddad at the nursing home, even before he moved in. He helped start Holy Trinity Nursing and Rehabilitation Center in Worcester so that his family and others in the Eastern Orthodox Church would be taken care of in their old age.

Last year, when Haddad started falling at home, he moved into the nursing home. One night this month, he got up to use the bathroom, fell, and hit his head on the nightstand. But the staff, according to his family, did not call for medical help. Instead, they put Haddad, 87, back in bed. Thirty-six hours later, he was dead.

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Two staff members have been dismissed and state nursing home regulators are investigating the death of the man whose devotion to the place was legendary.

As board president, he kept an office there, and his grandchildren often played checkers and cards with the elderly residents.

“He was connected to it and proud of it,” said his daughter, Lorna Haddad. “It was his place. He loved it. He would say, ‘Why wouldn’t anyone want to go there?’”

The state Department of Public Health says if its probe uncovers any problems, the 113-bed home must correct them. Fines and other sanctions are also possible.

Based on surveys and complaints over the last three years, the department currently ranks Holy Trinity in the bottom quarter in the state for nursing home quality. US data also indicate that 6.8 percent of Holy Trinity’s residents suffered major injuries from falls in the last year, more than double the average reported rate of 3.3 percent for state nursing homes.

“The care and safety of nursing home residents is a top priority for the Department of Public Health,” said Tom Lyons, a spokesman, who confirmed the agency is “conducting a detailed investigation.’’

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Trinity’s administrator, Jerry Shaffer, did not return messages. But an internal nursing home report on the events leading up to Haddad’s death found that a nurse who was working that night “failed to follow what is considered protocol regarding accidents and investigations.” The report does not say what that protocol is. A nursing home aide also failed to report the fall to workers on the morning shift, according to the report, which Lorna Haddad shared with the Globe.

The aide, according to the report, contended that the nurse had urged staff members not to the report the fall. The nurse refused to be interviewed for the internal investigation. Holy Trinity has fired the aide and cut ties with the nurse, who worked for a private contractor, the report says.

State regulations require nursing homes to report any fall that results in a serious injury to a resident.

“I’m so mad,” Lorna Haddad said. “They should have called an ambulance. They should have called my mother, and made a report that he fell.”

“They should have called an ambulance. They should have called my mother,” said Lorna Haddad.
“They should have called an ambulance. They should have called my mother,” said Lorna Haddad.Nicholas Pfosi for The Boston Globe

A lifelong Worcester resident who loved jazz and ballroom dancing, Walter was active in the Eastern Orthodox Church, where he was a choir director, parish council president, Sunday school superintendent, and head of a council of 12 Worcester-area churches.

More than two decades ago, when he was working as an accountant, he helped raise money to build Holy Trinity. A family photo shows him beaming at the 1994 ribbon-cutting ceremony. He served 12 years on the nursing home’s board, including a stint as president.

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“Everyone who was there for more than a year knew the name Walter Haddad,” Lorna said. “He was a fixture. He would walk in and everyone would say, ‘Walter! Walter! Walter! How are you doing?’”

When he started falling last year, and his wife of 63 years, Christine, could no longer care for him, the family reluctantly moved Walter into Holy Trinity, despite concerns that it had declined in quality.

To ensure his safety, Walter was given a wheelchair with a belt that sets off an alarm when unbuckled, his daughter said. But he became frustrated when the staff wouldn’t respond to the alarm, so he disarmed the belt, his daughter said.

Instead, Walter was told to press a call button in his room if he needed to use the bathroom. But Haddad did not like waiting for help, and insisted on using the bathroom by himself, she said.

After watching the 11 o’clock news on Aug. 5, he got up to use the bathroom without pressing the call button, stumbled, and struck the nightstand, Lorna Haddad said. At some point, the nurse and the aide put Walter back in bed, she said. When Walter’s wife and son Michael came to visit him the next morning, he was slurring his words.

Michael Haddad told the staff to call an ambulance. At Saint Vincent Hospital in Worcester, an emergency room doctor told the family that Walter had a “brain bleed” and sent him to the trauma unit at University of Massachusetts Medical Center. There, a neurologist told the family the bleeding was extensive, and nothing more could be done. Walter, surrounded by family, died just before 10:30 a.m. on Aug. 7.

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Four priests, a deacon, and a bishop attended the funeral, and an altar boy carried a cross in front of the casket as a sign of respect for Walter’s service to the church, Lorna Haddad said. The daughter said she wants Holy Trinity to take responsibility for the safety of its residents.

“It’s not just him,” she said. “This shouldn’t happen to anyone.”


Michael Levenson can be reached at mlevenson@globe.com. Follow him on Twitter @mlevenson.