Just a week after the Department of Health and Human Services reported that abuse in nursing homes is "widespread" and under-reported, a nurse at a Phoenix-area assisted living facility says he was forced to live to investigators to cover up a patient's death.
Just before 8 p.m. on March 15, staff found 83-year-old Wendy Rhymes in the dining room of Broadway Mesa Village with a massive gash on the top of her head and with a faint-to-no pulse.
There are no cameras at the assisted living home, so it's also unknown how and why Rhymes ended up face down in a dark, empty room.
Broadway Mesa Village staff panicked once they found her and didn't perform CPR or other life-saving measures, according to staff interviews, investigative records, and a 911 audio recording.
A former nurse claims he was asked to lie by Broadway Mesa Village interim director Barbara Stein about the care that staff provided to Rhymes before first responders arrived.
"I think they were trying to cover it up," said the former nurse, who spoke on the condition of anonymity. "(Stein) wanted me to say that all of the employees did CPR and everything they were supposed to do when they just stood back and they did nothing."
Attorneys and a top executive for the company that owns Broadway Mesa Village are strongly denying the allegations and claim the former employee is lying.
The nurse told the same story to Mesa police investigators, who also doubt Broadway Mesa Village's version of events. One detective documented repeated discrepancies and reported Stein's "possible fabrication and misrepresentation of facts."
The 911 call and response
The 911 call lasts 3 minutes and 39 seconds.
Listen to the full 911 call in the video player above.
Throughout the call, the dispatcher struggled to get clear answers from Broadway Mesa Village staff about Rhymes' condition, whether she was breathing, and if any staff members were performing CPR.
No one did perform CPR, records show.
When firefighters arrived, Rhymes was found still face down in the prone position.
"The staff was in disarray and bewilderment," according to an official statement by a Mesa Fire Department captain.
Firefighters were able to regain a pulse and took Rhymes to a nearby hospital, where she died later that night. On her head, there was a large gash that required 20 staples to close, according to a picture of the wound.
What caused the wound is a mystery.
Mesa police were not called out to the scene the night of the incident, and the scene was later cleaned up by facility staff. Officers were not informed of the death until the family asked them to investigate four days later.
Family members say Broadway Mesa Village told them that Rhymes fell and hit her head on a nearby piano.
Interim director Barbara Stein told police that's also what she believed happened.
But the Mesa fire captain told investigators that when his crew got to the scene, there was "no obvious indication the patient may have struck her head on the piano, and there was no evidence of a blood trail near the patient to indicate movement."
A scan at the hospital would reveal that Rhymes had two broken bones in her neck, records show. But there were no fractures on her skull.
There won't be any additional answers from an autopsy. The Office of the Medical Examiner declined jurisdiction and has ruled the death as accidental, according to police.
Who's telling the truth?
The day after Rhymes' death, the former nurse said Stein asked him to write a statement claiming that staff acted appropriately, performed CPR, and did what was necessary before firefighters came to the scene.
After he refused and because of other patient care issues he had raised, the nurse claims he was terminated within two weeks by Broadway Mesa Village and its parent company Pegasus Senior Living.
"(They) were being persistent in trying to find something to get me terminated," the former nurse said.
In response, Pegasus Chief Operating Officer Matthew Thornton denied the allegations and said the former employee was not telling the truth. Attorneys for the company later issued a statement further denying the claims.
"Further, Broadway Mesa Village and its employees have never denied that CPR was not performed on Wendy Rhymes. It is clear from the Mesa Police Department report, and the recording of the 911 call, that CPR was not performed. Very good medical reasons exist to explain why CPR was not performed, which are contained in the medical records for Ms. Rhymes. We are prohibited from disclosing these reasons due to the restrictions set forth in the Health Insurance Portability and Accountability Act, also known as HIPAA."
Before the above statement, the staff had never listed Rhymes' medical records as a reason for not performing CPR to save her life. In official statements to the Arizona Department of Health Service and the Mesa police, company officials never cited Rhymes' medical condition as a reason for not performing CPR.
Here are several examples from the Mesa police investigation:
- "Barb said because of the situation and the way Wendy looked, they did not want to touch or initiate CPR, saying Wendy's head looked 'funny.'"
- "Barb claimed staff was instructed not to move Wendy by the 9-1-1 operator and that was why they did not perform CPR."
- "In a review of the (Arizona Department of Health Services Reportable Event Report) provided by Barb Stein, I noted it stated staff was told not to move Wendy Rhymes, which was not consistent with the 9-1-1 tape."
The discrepancies led the Mesa police detective to call the Arizona Department of Health Services in April and report "care concerns regarding Broadway Mesa Village as well as possible fabrication or mis-representation of facts by the Interim Executive Director Barb Stein."
Stein did not respond to two emails seeking comment. Instead, she forwarded those emails to top executives.
The statement by Broadway Mesa Village's attorneys, also says, "Moreover, it is public record that the Medical Examiner has deemed Ms. Rhymes' death accidental and the Department of Health Services closed their investigation concluding unsubstantiated allegations. No citations were issued."
The health department is now re-examining the case and looking into instances of other residents who died at the facility earlier this year.
The former nurse also said he was interviewed Thursday by a state health department surveyor.
This story was originally published by Dave Biscobing on KNXV in Phoenix