It’s every adult’s worst nightmare. An elderly person goes into a care facility, but they don’t make it out alive. That’s what happened to Barbara Jarvis, an 84-year-old resident at the Van Duyn nursing home in Syracuse, New York. She was found dead in her room on December 13th of last year, and authorities are finally getting to the bottom of the situation after an ongoing thorough review.
Investigating What Went Wrong
An independent investigation from the state department of health shows that Jarvis slipped and fell in her room while trying to use the bathroom. Part of her hospital gown got caught on the door handle, causing her to accidentally hang herself to death, according to the Onondaga County Sheriff’s Office.
Patrick Calli, the administrator of the nursing home, refused to comment, citing patient privacy laws, but the facility released a prepared statement. “The Van Duyn family is saddened by the events surrounding Ms. Jarvis and that an accidental fall while she was a resident in our facility led to her passing”, Calli said.
The report says Jarvis needed an escort during ambulation, as per her care plan, but the nursing aides on staff did not read the plan. They were required to read her report daily, but due to negligence, Jarvis was forced to go it alone.
The report also shows a history of negligence on the part of the Van Duyn staff. Records indicate that Jarvis fell twice before her fatal incident last December. It was after these falls that the staff updated her care plan with “needed extensive assistance” in terms of getting in and out of bed and using the bathroom.
The facility’s assistant director of physical therapy added that Jarvis “… was not able to demonstrate she could safely ambulate on their (sic) own and he would not expect staff to allow independent ambulation because of the risk of falling.”
Jarvis was last seen alive at 12:35 AM on December 13th. “The resident then stumbled to her knees, tightening the tie which then partially encircled her neck. This acted as a noose compressing the vessels at the sides of the neck,” the report says. A nursing aide found her dead in her room at 1:55 AM.
A History of Noncompliance
Jarvis died just three months after moving into the Van Duyn nursing home, which has had a history of substandard care for more than a decade.
The facility has received three times more citations from the state health department than the average NY nursing home over the last four years. It’s been sued for negligence or malpractice in the state’s Supreme Court 20 times since 2016, more than any nursing home in Onondaga County.
Meanwhile, Van Duyn has a one-star rating with Medicaid. It has a reputation for being understaffed. Residents get just one hour and 29 minutes of care a day, more than an hour less than the average nursing home resident.
During recent inspections, regulators found that 18 residents failed to receive their medications when due because the facility forgot to assign a nurse to hand them out. They also cited the facility for failing to protect residents from abuse. In one instance, a nurse allegedly pushed a resident in a wheelchair into a wall, hurting their leg. The nurse was then fired for her actions.
In another case, the facility was flagged for letting a dead body decompose inside an unrefrigerated morgue until the funeral director could pick it up. The report showed the morgue was somewhere between 80 and 90 degrees.
It was deemed a “special focus facility” in 2011, earning a place on a list of the country’s worst-performing nursing homes. These facilities are closely watched by regulators. If they don’t improve their performance, they could lose Medicaid/Medicare funding.
Searching for Answers
John W. Jarvis, Barbara’s son, says his mother’s death could have been prevented. “I think she was just neglected,” he told reporters. He says his mother lost 27 pounds during her short time at the facility.
He says his mother moved closer to North Carolina when she came down with dementia to be closer to her son, but he didn’t have enough time to care for her between working full-time and caring for his disabled wife. That’s why he ultimately decided to put her in Van Duyn.
“I had a lot on my plate. It was overwhelming,” he said. That’s a decision he’s sadly come to regret.
Jarvis’ granddaughter, Alyssa Jarvis Dias, works as a nurse practitioner in North Carolina. She says she’s been advocating for patients over the last ten years, but her grandmother’s death put things in perspective, calling it a “bitter pill to swallow.”
“I wouldn’t want any other family to have to go through this,” she said.