The nurse’s aide was busy getting a patient ready for bed when she noticed a commotion on the other side of the room behind a privacy curtain. She could hear Russ Bonanno, a 94-year-old veteran, shouting “ow, ow, ow.”
“It sounded like fighting’” said Julee, who asked that her last name not be used out of fear of retaliation. But when she walked to the other side of the room, she saw another aide trying to hoist Bonanno from his wheelchair to his bed, normally a two-person job.
Then, as she watched, Julee said, the other aide simply tossed the elderly dementia patient onto the bed.
“Let me tell you how brutal that guy was with the veteran,” Julee wrote to her supervisor two days after the May 18 incident. “After he was done, (we) went and checked Mr. Bonanno. The guy was wet. Everything needed to be changed.”
The aide who roughly handled Bonanno quietly resigned, but the aide who blew the whistle was fired two weeks later. She said her supervisor told her she had attendance problems.
Welcome to one of the lowest rated nursing homes for veterans in the United States. Located at the Edith Nourse Rogers Memorial Veterans Hospital in Bedford, it is among just 11 nationwide to earn a one-star rating from the Department of Veterans Affairs based on both overall quality and the results of surprise inspections.
Bedford’s rating reflected an array of problems caring for the more than 200 veterans who live there, including bed sores, high rates of medication, and general decline of veterans’ health, according to documents obtained by The Boston Globe and USA Today, which have been jointly investigating VA nursing homes.
The poor grade for surprise inspections, meanwhile, reflected in part the staff’s hands-on treatment of residents. In 2017, inspectors from the Long Term Care Institute found several instances of neglect including a veteran lying naked in bed covered by a urine- and feces-stained sheet. Their report cited another veteran who struggled to shove food into his mouth with his hands after trying unsuccessfully to use a spoon. Staffers were nearby.
The report followed the case of another resident who died in his bed in July 2016 while the nurse’s aide who was supposed to check on him played video games on her computer. The aide, who has since resigned, was supposed to check on Bill Nutter hourly because he had a condition that could cause his heart to stop without warning.
Now, the Bedford VA has its fourth director in as many years, including one who was demoted in 2016 for undisclosed ethical transgressions. The new director, Joan Clifford, previously a VA executive in Washington, D.C., defended the quality of care there and said the team is always striving to improve it.
“On my first day there I walked all the units and I was struck at how well cared for the nursing home patients were,” said Clifford, who came to Bedford early this year.
Clifford denied that Julee was fired for reporting the alleged abuse of Bonanno and said there were other issues she could not discuss. However, she acknowledged that the aide accused of poor care was allowed to resign. If he hadn’t, she said, disciplinary “action would have been taken.”
Clifford also said the one-star quality rating the facility received from the VA didn’t take into account the complexity of the patient population, which includes many patients with dementia or psychiatric problems.
“There have been improvements and we’re expecting a better score next time,” she said.
Her reassurances mean little to the family of Charles Amidon, a highly decorated veteran who once served as medical adviser to the South Vietnamese army. For the past four years, the retired lieutenant colonel has been living in a room in Bedford VA’s Building 4, the same building where Nutter died.
“We have experiences with civilian hospitals,” said Amidon’s son Christopher, noting that his father had stayed at a private long-term care facility. “You see the level of care. It was like night and day . . . (In Bedford,) I noticed patients in wheelchairs sitting in the hallway who hadn’t been bathed. They had dandruff and heavy stains.”
Clifford said she couldn’t discuss any individual veteran’s care because neither they nor their family members signed necessary releases.
The troubles in Bedford are part of a larger concern for the VA’s care of elderly veterans across the country. Earlier this year, the Globe and USA Today revealed that internal ratings showed 60 VA nursing homes — nearly half of such facilities nationwide — received the lowest ranking for quality as of Dec. 31, 2017. (Among the homes rated lowest for quality in the first quarter this year, only 11, including Bedford, also got one-star ratings for surprise inspections.)
But the agency only released the ratings to the public after the two news organizations began asking questions about them.
In late 2017, the VA gave one star to only 13 nursing homes nationwide, including Bedford. The number of worst-rated facilities increased to 60 three months later, when the VA changed the ratings to compare VA nursing homes to private facilities rather than just to each other.
Under the new system, Bedford rated worse than private nursing home averages on 10 of 11 key quality indicators last year. Across the country, more than 100 VA nursing homes scored worse than private nursing homes on a majority of the indicators.
VA spokesman Curt Cashour said the agency is using the data “to drive improvements across the system,” noting that only one VA nursing home saw a significant decline in its quality rating this year.
Cashour has said that VA nursing homes score lower on key quality indicators because they have residents with more complex medical conditions, but that “overall,” the VA nursing home system “compares closely” with the private sector.
This much is clear: The Bedford VA nursing home has been buffeted by controversy since 2016 when director Christine Croteau was transferred to Washington, D.C., amid an ethics investigation. David Shulkin, a former VA secretary, confirmed that she had been demoted but did not disclose the reasons.
Since then, the Bedford nursing home has had two interim directors before Clifford, who once served as a nurse executive at the Boston VA, took over in March. In between Croteau’s departure and Clifford’s arrival, the Globe revealed the circumstances surrounding the death of Nutter, whose family is preparing to sue the VA for the aide’s inattentive care.
The aide, Patricia Waible, eventually admitted that she was playing video games on her computer and didn’t check on Nutter on the night he died, the Globe reported in October.
“I hold the VA responsible for all of this. They’re responsible for their employees,” said Nutter’s daughter, Brigitte Darton. “How many other people did this lady cause issues with?”
Among current residents of the Bedford nursing home, opinions of the care are mixed.
Amidon is now largely bed-ridden with advanced Parkinson’s disease, unable to read or watch TV much, his wife, Helga, said, because the VA-issued glasses don’t help his poor eyesight. She also said that before early July, he hadn’t showered since April, though he may have been cleaned with a cloth in his bed.
“The care is adequate,” Amidon himself said recently. But his family doesn’t agree. They say he’s afraid if he complains he’ll be treated even worse. “There are some good people here,” he added.
Amidon’s son Christopher said his father is being overly polite. Christopher said he saw a nurse mocking the way his father walked, hunched over and breathing heavily. His father and other veterans sometimes waited hours for nurses to respond when they pressed their buzzers for help.
In January of this year, he said, his father called and said the staff had been slapping him.
In May of 2017, he came down with scabies but the contagious rash wasn’t diagnosed for five months, his wife said.
Nursing home director Clifford said she was surprised to hear of the family’s complaints and would like to hear from the family firsthand.
“I’m really disappointed. I want things out in the open so I can address them,” she said. “My ultimate responsibility is to provide the best care for these veterans in a dignified manner. I don’t want the few cases that are not great to overshadow the great cases.”
Clifford confirmed that she was troubled by the reported manhandling of Russ Bonanno, and she said the issue was resolved when the employee, Anthony Santos, agreed to resign.
For his part, Santos denied the incident happened. “It was made-up story because I am not popular because I won’t be yelled at or cursed at (by) management or staff. I transferred the veteran,” he wrote in an e-mail, adding that he “quit because (of) the toxic work environment.”
Julee remains suspicious that she was targeted for being a whistle-blower, noting that she was never warned about attendance issues and she was popular with patients and their families.
Nick Bonanno, Russ’s son, was upset his father was manhandled and that Julee was let go — she stood out among the employees for her compassion and kindness, he said.
“She made a real effort to engage the vets — singing, chatting, joking with them, creating a social connection that is so important,” he said, adding that there are other caring staffers at the facility. But Julee, he said, “was very committed to caring for these men, not just showing up to work a shift. I only know what I saw, and what I saw was positive.”
As for Charles Amidon, his wife and son say that now that he is in the late stages of Parkinson’s disease, they are less afraid to speak their minds about the quality of the care in Bedford. Previously, they had feared that anything they said could result in worse care for him.
“If I won the lottery, I would take my father out of there,” said Christopher, explaining that placing his father in a high-quality private nursing home was unaffordable — costing tens of thousands of dollars a month.
Now, all they hope for is that they can take Charles Amidon to the family’s summer home on Orr’s Island in Maine one last time, though they doubt their wish will come true.
“The morning light there is beautiful,” Helga Amidon said.
Andrea Estes can be reached at firstname.lastname@example.org.