Unnatural causes

When Patricia Fraga arrived at a Chico nursing home for her weekly visit with her father, she noticed that he looked a little under the weather and didn’t have his usual appetite. But staff there told Fraga, who lives in Concord, that her dad just had a case of the flu that was going around. The next day, Jack Ellington was dead.

Ellington was 80 years old and suffering from mid-stage Alzheimer’s disease, so when he died on March 22, 2002, his family was surprised but not shocked. They accepted his death and started the grieving process for a “great old guy” whose life had centered on his family and farm in the tiny Glenn County community of Ord Bend.

Unbeknownst to his family, the state Health and Human Services Agency launched an investigation, and on Dec. 30, 2002, it cited Chico Creek Care & Rehabilitation for actions it believes resulted in Ellington’s death. The state also fined its corporate owner, SunBridge Healthcare Corp. of Albuquerque, $100,000, the largest amount possible under the law.

The citation was classified “AA,” the most serious, meaning that the violation of regulations “was a direct proximate cause of the death of the patient.” Less than one week later, a second man died (see note at left) at the nursing home, resulting in another citation and fine for SunBridge.

SunBridge was already under order to increase staffing and improve treatment of patients after a statewide civil settlement negotiated by California Attorney General Bill Lockyer, who also went after the corporation criminally for what he called “poor-quality care.”

“We think the facility has a lot of explaining to do to the attorney general and to the family members,” said Prescott Cole, staff attorney for San Francisco-based California Advocates for Nursing Home Reform (CANHR).

SunBridge Spokesperson Melissa Tommaso of Albuquerque (local employees don’t give interviews) declined to comment, other than to say that the two citations stemming from the March 2002 deaths are related to patient care issues and the chain is appealing them.

It was Enloe Medical Center officials who felt the coroner should be contacted. No autopsy was done, but a written report stated that Ellington’s probable cause of death was “internal bleeding and related complications.” Another doctor reviewing the case notes suggested that the hemorrhaging could have been related to pain medication Ellington had been taking.

The state determined that there were many physical signs that Ellington was bleeding internally. His heart rate was slowed, and he had no blood pressure. Starting at 5 a.m. on March 22, a nurse tried twice to contact a physician, who arrived a half-hour later. Only then was an ambulance called. The state found that, against facility protocol, staff “failed to activate emergency services, call 911 or an ambulance when a declining unstable patient was found with no blood pressure, which resulted in his death 66 minutes later.”

All of this unfolded without the knowledge of Ellington’s relatives. The family learned of the investigation, citation and fine when contacted by the News & Review.

Ellington’s younger brother, Thomas, was startled to learn that there was anything about the death that commanded scrutiny by state overseers.

“We just got a call that they had put him in the hospital and he passed away,” said Thomas Ellington, who lives in Oakland. “His health was good as far as I know. He was living a happy life.”

When his brother died, Ellington said, “I had no reason to question it. Dumb us. You think, gee, he could have been happy for a few more years.”

Jack Ellington was at Chico Creek Care & Rehabilitation to spend a month recovering from back problems. The day he died was the day he was to be released, and the family had been checking out board-and-care facilities where he could stay.

Ellington was hoping to come home, where just seven years earlier he had put in 77 acres of young almond trees on his orchard. His wife, Florence, died after a brief illness in 1991. But his son, Harvey, lived on the same property and checked in on his dad often.

Now, Harvey Ellington is questioning whether it was really his father’s “time” to go. “We didn’t think he was sick,” Ellington remembered. “There were a lot of things that didn’t compute.”

Fraga said the family didn’t learn of Ellington’s death until Friday night, and he had died at 6:06 that morning.

“I felt like I shouldn’t have gone [away from Chico],” said Fraga, feeling some regret. “I should have stayed. He did look peaked, and he obviously wasn’t feeling well.”

The advocacy group CANHR reviews citations issued by the state and puts out summaries of those it considers most worrisome.

The case of Jack Ellington, whose name was not released but was determined by the News & Review using death records, stood out.

Cole, the attorney, said AA-level citations are “very rare,” with fewer than a dozen being issued each year in California. “That’s a big deal,” he said. “[An] AA [citation means] death, and they did it.”

Typically, he acknowledged, corporations challenge the citation and fine, and they often win because DHS lawyers are overworked and nursing home attorneys are skilled at finding holes in the evidence. For the corporations, he charged, “it’s just a cost of doing business.”

That doesn’t make Cole feel any better. "What if one of these things happened in a day care center, for kids?"