The state Department of Community Health inspected Alzheimer’s Care of Commerce in April but documented none of the abusive treatment that led the GBI to raid the center and issue arrest warrants for the owner and employees Tuesday.
The GBI investigation, also launched in April, amassed evidence of a long list of abuses: patients being slapped, restrained with bed sheets, doused with water and subjected to double-diapering so the staff would have to change them less frequently.
The GBI is also investigating three deaths at the home that occurred since the first of the year, GBI Director Vernon Keenan said Wednesday. In addition, he said, investigators will review the center’s financial records for possible irregularities.
“Things were out of control,” Keenan said Wednesday of conditions at the center. “The facility was not being managed professionally. Checks and balances were not in place, Professional protocols were not being followed.”
Alzheimer’s Care of Commerce is licensed as a personal care home, a type of facility that falls somewhere between a boarding house and a nursing home.
A year ago, The Atlanta Journal-Constitution revealed widespread problems in Georgia’s personal care homes, including what advocates for the elderly and disabled called ineffectual state oversight. The state rarely took strong action, even against operators who repeatedly violated health and safety standards, the AJC’s investigation found.
Keenan declined to comment on DCH’s oversight of the Commerce facility, saying he’s unfamiliar with the agency’s inspection process.
State Sen. Renee Unterman, R-Buford, who has pressed the Legislature on elder abuse issues, said she was concerned that the state DCH did not uncover the problems sooner. She said a newly created state task force on Alzheimer’s would be examining how agencies “regulate all these facilities.”
DCH declined an interview request Wednesday. “The department is unable to comment on any items related to this open and ongoing investigation,” agency spokeswoman Pam Keene said in an email.
The GBI investigation that led to Tuesdays arrest warrants began with complaints in late March to Commerce Police Chief John Gaissert. The complaints described allegations of what Gaissert described as “mistreatment that would be consistent with elderly abuse.”
According to the department’s records, the incidents that gave rise to the complaints stretched back to August 2012.
On April 11, DCH performed a inspection of the facility, part of its program of inspecting personal care homes every 18 to 24 months. The report, which is eight pages long, details problems not uncommon to such homes. They include ventilation issues, staff members not trained in the control of infectious diseases and a lack of documentation to show that all employees had been subjected to criminal background checks.
The lack of criminal background checks had also been noted in the previous DCH inspection, performed in 2011. GBI subsequently determined that some employees had prior felony convictions ranging from voluntary manslaughter to drug charges to identify theft. It is against state regulations for personal care homes to employ convicted felons.
The GBI began its probe in April, after Gaissert turned to it for help. As part of its investigation, GBI investigators “reached out” to DCH, an agency spokesman said in an email Wednesday.
In May, DCH performed another inspection at the Commerce facility, and found many more problems, including reports that staff had restrained patients with sheets. The report detailing that inspection, which runs to 32 pages, also found numerous instances of medications disappearing from the facility. It said staff had failed to investigate injuries to patients, failed to keep them clean, let patients wander away from the site and failed to give patients the proper medications.
A former staffer told an inspector that “staff kept a sheet tied around resident #1 day and night,” the report says.
In addition, the report said a staffer had left cookies laced with morphine around the office, and that another staffer had eaten some of them and become sleepy.
The GBI probe turned up many of the same problems. Keenan finds the reports of missing drugs particularly troubling.
“We have unaccounted for drugs, and we have intermingling of drugs between patients, ” he told the AJC Wednesday. “That’s an indication that things were out of control.”
In the past, DCH has seldom shut down homes, even when it has documented scores or hundreds of violations, the AJC reported in its investigation last year.
“Deficiencies in care, living conditions and record-keeping have piled up in scores of Georgia personal care homes, with the state rarely shutting down violators or levying heavy fines,” the paper reported. “An analysis of five years’ worth of inspections, violations and enforcement actions revealed that many frequent violators have faced nothing more than a fine of a few hundred dollars.”
At that time, DCH employed 19 inspectors to monitor conditions in the state’s roughly 2,000 personal care homes. Today, that number is 20, according to Keene’s email.
About half the state’s 2,000 personal care homes are located in metro Atlanta.
Ross Mason, the former head of the DCH board, said Wednesday that prior to about two years ago inspecting such facilities “was not an area of focus. We were not being proactive.” But he said the agency has made improvements since then.
Twenty-six patients were living at Alzheimer’s Care of Commerce when law enforcement officers swept in Tuesday to execute a search warrant, Keenan said.
The GBI temporarily took over the privately operated facility. The owner, Donna Wright, turned herself into authorities Tuesday evening and was released on a bond of $75,000. Sixteen of the 21 people for whom warrants were issued had been processed through the jail by Wednesday evening. They are charged with cruelty to a person 65 years of age or older, abuse, neglect and financial exploitation.
Wright’s attorney, Mo Wiltshire, said Wright and her husband owned and operated the facility for 18 years before the husband’s death about three years ago. Since then, Wiltshire said, Donna Wright has continued to run Alzheimer’s Care.
“They have tried to provide loving and secure and safe care,” Wiltshire said.