COLERAIN TOWNSHIP, OH (FOX19) - A FOX19 investigation is revealing what happened at a nursing home in June when an 83-year-old woman died just six weeks after arriving for therapy on a broken wrist.
Gloria Howell was an 83-year-old grandmother who had been living with her son in Colerain Township. He told FOX19 News in a phone conversation he expected her to come back to live with him soon.
But an Ohio Department of Health and Human Services investigative report, obtained by FOX19, shows that nurses realized Mrs. Howell's mind wasn't working as well anymore, that she couldn't stand-up by herself, and that she needed constant attention.
Yet the nursing home staff's own statements to the investigator show that on the afternoon of Sunday, June 10, Mrs. Howell was left alone. A woman identified as State Tested Nursing Aide #3 said she left Mrs. Howell in a recliner near the nurse's station around 12:15 p.m. Another nurse's aide, identified in the report as STNA #6 came by later and discovered that Mrs. Howell had her legs over the side of the recliner and appeared restless.
Mrs. Howell "was bound and determined to get out of the chair," STNA #6 told the investigator.
Yet STNA #6 didn't stay with Mrs. Howell or move her somewhere safer. The nurse's aide instead put Mrs. Howell's legs back in the correct position and left her there.
"No other staff were present," the investigator's report notes.
By 12:20 p.m., just five minutes after the first nurse's aide had put Mrs. Howell in the recliner, someone found her lying on the floor. There was a cut on her right eyebrow. She was bleeding badly.
In the 911 recording obtained by FOX19 News, the nurse assigned to Mrs. Howell that day tells the operator, "We just, we've been trying to get a PTI on her because she's been running high. So that's probably why she's bleeding so much."
A registered nurse tells FOX19 that PTI stands for "Pro Thrombin/International Normalized Ratio – this is a blood test that indicates how much time it takes the patient's blood to clot," he said.
Mrs. Howell was also in pain.
She was "mumbling and trying to lift her head and there was a puddle of blood on the floor," the state's investigator wrote after speaking with the nurse who discovered Mrs. Howell on the floor.
She "was moaning and grimacing," the report notes.
"An 83-year-old hurts just as bad as a 23-year-old," said Don Moore, a Cincinnati attorney who used to be an investigator for nursing homes.
We asked him to weigh-in on what happened at Triple Creek considering that Gloria's son told FOX19 that a nurse told him they were "really short-handed" the day his mother fell.
"Doing a poor job and having an excuse that we're inadequately equipped, that's not acceptable," Moore said. "That is negligence almost by its --- almost an admission of negligence."
The Louisville, Kentucky, company that owns Triple Creek sent us a statement that says "Improving our services is an ongoing process…"
Toward the end of the statement, the nursing home company added, "We take every precaution to ensure our residents' safety, and we believe this was an unfortunate, isolated incident."
Yet FOX19's investigation reveals that in the last year-and-a-half, federal and state agencies have threatened to take away Triple Creek's Medicare and Medicaid funding four times due to various violations.
Every time, though, Triple Creek submits a new plan claiming to have improved. And the agencies back off.
Attorney Don Moore has seen this a lot.
"Patients suffer as a result of it," he said.
The back-and-forth between healthcare providers and the agencies that oversee them is pretty common, he said, though the "general public doesn't get to know that."
A spokeswoman for Ohio's health department told us authorities have not shut down Triple Creek because, at least until now, the problems there have not been extreme.
By July 26, 45 days after Mrs. Howell died, the state said Triple Creek was in full compliance.
Technically, the Butler County coroner's investigation is still open.
We're told the coroner probably won't issue her final report for another four to six weeks.
But in the preliminary results FOX19 obtained, a pathologist lists Mrs. Howell's death as being "due to (the) ground level fall."
The manner of death: accidental.
However, it's one Mrs. Howell's family believes could've been prevented.