By ALYSSA LENHOFF
and Doug Livingston
The News Outlet
As an ombudsman for the Area Agency on Aging, John Saulitis sees the best and the worst in Northeast Ohio’s nursing facilities.
“Sometimes you see violations that are so serious that — not just as an ombudsman but as a member of the public — you look at that [and ask], ‘Why didn’t someone pay or have to face consequences for this particular activity?’ ”
Across Northeast Ohio, police and inspection reports hint at some of the most egregious actions committed in nursing homes: three sexual-assault cases in a dementia unit at a Canton facility; a 90-year-old woman beaten with a clothes hanger at a Stow facility; two elderly residents physically abused by a nurse’s aide in a Boardman facility; and pending investigations and charges throughout Ohio’s network of 956 nursing homes.
Officer Kevin Green of the Stow Police Department said he believes that officials only find out about and prosecute a small percent of the cases of abuse in facilities.
“It’s the hidden dragon,” said Green, who is the interim senior-services officer for his department. “It’s a very frustrating crime because there is an element of trust that is violated in these cases. These people and families have placed their trust in a facility, and that bond is broken when there is abuse.”
In 2011, the Ohio Department of Health cited Ohio nursing homes 198 times for failing to adequately report abuse or neglect, or hiring someone with a history of abusing or neglecting patients. Also, facilities were cited 46 times for failing to keep patients free of “verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion.”
Even in cases where the police do get involved, investigations often don’t lead to criminal charges.
“Most of the time, you don’t have witnesses or victims who are capable of telling you what happened,” said Detective Rick Balog of the Boardman Police Department.
Some prosecutors across Northeast Ohio can’t recall a single case in which a facility or its management was held criminally liable.
The reason, most prosecutors and elder-care advocates say, is that, aside from finding a credible witness, facilities that care for the elderly and the disabled must exhibit a “knowingness” that wrongdoing is happening and ignore that potential harm before being held criminally culpable.
But reports and the lack of charges indicate that even if a facility is aware of a potential danger and is found to inadequately address that danger, the facility may not incur criminal charges.
Despite this, Gabe Wildman, a Trumbull County prosecutor, said no one is above being criminally charged for neglect or abuse.
He refers to the Ohio Revised Code, that states “no person who owns, operates, or administers … a care facility shall … commit abuse against a resident or patient of the facility; commit gross neglect against a resident or patient of the facility; commit neglect against a resident or patient of the facility.”
Wildman and other prosecutors acknowledge, however, that charging a facility or administrator becomes difficult because knowledge of the neglect and abuse must be established.
While it is rare for a facility or an administrator to face charges, it is not so rare to see charges against an employee.
Such was the case at Briarfield of Boardman, a nursing home on Boardman-Canfield Road.
Just before 8 a.m. March 4, Sara Reyes-Carmona had begun her first day as a nurse’s aide at the facility, which is now known as Vista Care.
Reyes-Carmona was assigned to train with Jolita Monserrat, another aide at the home, according to a Boardman police report.
The women were working with two Alzheimer’s patients when Reyes-Carmona said she saw Monserrat grab a 96-year-old woman by the wrist, shove her and then slap another resident, an 80-year-old woman suffering from dementia.
It was disturbing enough that Reyes-Carmona called the nursing home’s management to report Monserrat for abuse, the report said.
Boardman police arrived, and after seeing bruises on the two women that were consistent with Reyes-Carmona’s statement, filed charges against Monserrat.
In May, a Mahoning County grand jury indicted Monserrat, 33, of Youngstown on two counts of assault and two counts of patient abuse. Her next court appearance is Dec. 19.
Balog, who helped investigate the case against Monserrat, said this case is unique because a staff member witnessed the alleged abuse.
Matt Parkes, the administrator of Vista Center of Boardman, was not at the facility when the purported incident happened but said the best way to keep residents safe is to have enough administrative staff wandering through the facility.
“I tell our administrative team that the more they are in their offices and not on the floor, the less they are doing their jobs. They need to be out and watching,” he said.
But even Parkes admits that direct oversight alone isn’t enough. He acknowledges that it’s impossible to watch every room, every nurse’s aide and every resident 24 hours a day.
Also, Parkes said state laws are inadequate to prevent troubled nursing aides from finding jobs at other homes.
For example, he said aides are permitted to start working at a nursing home while a background check is being performed, which can sometimes take several weeks. Ohio law allows nursing homes to employ people for up to six months before having results of background checks.
Also, in the few cases in Ohio where charges have been brought against aides, they are still certified to work until convicted.
Monserrat, for example, who has been charged with two felonies, was listed in “good standing” in November on the Ohio Department of Health’s Nurse Aide registry. Her license, issued on June 9, 2009, expires March 6, 2014.
Three months before being hired at Briarfield, Monserrat was arrested on a felony drug charge. She later reached a plea agreement and entered a no-contest plea to a misdemeanor charge of possession of dangerous drugs. The Ohio Administrative Code lists about 50 offenses, ranging from murder to possession of drugs, as crimes that disqualify someone from serving as a nurse’s aide in Ohio, but the type of drug offense Monserrat was charged with was not on the list.
She was sentenced to six months of probation and ordered to pay fines. She landed her job at Briarfield while she was still on probation.
Since June 2011, three residents of McKinley Healthcare Center in Canton have walked out of the facility and wandered in the community.
Jackson Township police found one resident less than five miles northwest of the facility. Another was found at Affinity Medical Center in Massillon, more than eight miles away. The third is still missing.
McKinley also had a rash of sexual-abuse instances in its dementia unit beginning in February 2011, according to a health department report.
The first occurred when another resident, William Burris, 80, who was named in the police report, climbed into bed with a female resident.
Burris was identified by the nursing home as being “at risk for wandering.” The staff was advised to “redirect [Burris] as needed from touching other residents,” said the state inspection report.
A motion sensor was placed on Burris’ door for 48 hours after the incident. Then it was removed, the report states.
Four months later, he was seen inappropriately touching that same woman. He was sent to a hospital “for evaluation for being a threat to others and being sexually inappropriate.”
Burris returned to McKin-ley, and the facility was told to address his threat to other patients.
Less than a month later, a nurse’s aide found Burris kneeling beside the same woman’s bed, fondling her.
That’s when Burris was discharged from the facility and subsequently arrested by Canton police and charged with gross sexual imposition, a fourth-degree felony.
Burris appeared before Stark County Judge Lee Sinclair and was found to be incompetent to stand trial.
TheNewsOutlet.org is a collaborative effort among the Youngstown State University journalism program, Kent State University, University of Akron and professional media outlets including The Vindicator.