Posed for Death, page 8
“This started with the case of a senior who apparently died in his sleep. But on further investigation, we realized that his heart had not just stopped. It looks like an accidental death, but I want to understand all the circumstances around it. Get a real feel for what the mitigating factors were.”
“And what does that have to do with Champlain House?”
“I was wondering if you could tell me about how you handle restraints. Or any safety measures that end up restricting patients’ freedom of movement. I have no idea what the regulations are or what protocols you normally follow. What you would consider safe or not safe.”
Able sucked in his cheeks, thinking about this. “I see. Well… the first thing you should know is that there is a very wide range. And it is all based on a resident’s needs. We want to restrict their movements as little as possible, of course. Great pains are taken to ensure that they are placed in the least restrictive environment possible and that their movements are as free as they can be.” He pressed his palms together and touched them to the front of his face, tapping thoughtfully. “That said, a resident’s safety is paramount. We cannot let people hurt themselves because we are not comfortable with implementing the restrictions necessary.”
Kenzie nodded. So far, it felt like all she was getting was double-talk. Nothing at all informative. “That all sounds good,” she told him. “But it’s theoretical instead of practical. Can we talk about actual practices and examples?”
Able shrugged and nodded. “Fair enough, I suppose,” he agreed.
“So far, I’ve only seen your independent living wing, and all of the residents there are… independent. No restrictions on their movement, as far as I could see.”
“Very little,” Able agreed. “We ask them to be back in their rooms for lights out and to keep us informed of their movements in case something happens, and we need to track them down. There is the occasional argument or altercation, and then we ask people to return to their rooms. But on the whole, yes, they’re allowed to go where they like, participate in the various activities, make friends… We want them to be as independent as possible. We foster that attitude as much as we can. The more independent they are, the more stimulation and responsibility they have, the better it is for their brains. It helps them to make connections and remember things. To fight off depression. Lowers risk of dementia.”
“But you have other units as well. You have a dementia unit?”
“Yes.” He tapped his fingers on the desk, his mouth pursing slightly. He wasn’t as excited to talk about the dementia unit as he was to talk about the more active and pleasant independent living wing. Kenzie could understand that. “Unfortunately, not everyone stays at the peak of health. Our bodies and brains degenerate over time and, even if you are doing all the things that are supposed to be protective, you can’t completely eliminate stroke, high blood pressure, viruses and infections, and Alzheimer’s disease. There will always be people who can no longer look after themselves or even remember who they are. It is a very sad situation. And I hope that we help our residents’ families to feel better about it. To know that they are doing everything they can for their loved ones. That they’re being treated with dignity and respect and given all of the physical and mental attention they need.”
“I’m sure that the ones that can afford your rates are very happy that you are taking care of their family members,” Kenzie agreed, watching Able closely for his reaction to this somewhat backhanded comment.
“Our rates are quite reasonable, all things considered,” Able said without apparent offense. “You remember that they are getting twenty-four-hour care, fully qualified nurses, that they are being monitored closely physically and over camera feeds. These things cost money. And there are bursary and assistance programs. We do our best to help families navigate those programs and applications so they can afford to care for their loved ones.”
“And then they don’t have to worry about what might happen to the person if they stay at home.”
Able looked serious. “We sometimes have to speak very plainly to families who think they can continue to care for their loved ones at home. A husband or wife just isn’t equipped for the responsibility of caring for a person’s every need, especially in complex medical cases. We try to help them see that caregiver burnout and the risks of having someone in their home without that twenty-four-hour nursing care and surveillance are just too high. You can’t do it forever. Sooner or later, the patient suffers. And unfortunately, so does the family. And then either there is a tragic end to the situation, or it becomes an emergency and they don’t have the time to find the right facility. Instead, they have to go with whatever facility is able to take a new patient with complex needs.”
Kenzie nodded slowly. “I guess that must happen a lot.”
“It does. People think they can care for their loved ones at home until the end, but they can’t. They have in their minds that nursing homes are a modern phenomenon and, before that, everyone took care of their family members by themselves. So it must be possible. But that isn’t really the way things were for our forefathers. Yes, they took care of grandma and grandpa because they had no other choice, but there was also no medical care, so those family members did not live very long. And there are cultures where they were simply left on a mountain to die. People with dementia or psychosis were locked up in insane asylums for the rest of their lives, which again, were very short. Modern nursing homes are not taking the job away from the families. They are making it possible for them to take care of their loved ones.”
“So you don’t think much of families who keep the person at home.”
“When they require treatment or twenty-four-hour supervision? No. Families need to realize when they can no longer provide the care their loved one needs.”
15
They were both silent. Kenzie thought over the Howard case. She still needed answers she didn’t have.
“Do you use poseys here?”
“Poseys? Yes, on occasion.” He pressed his lips together. “Not very long, though. There are other solutions. Restraint vests do pose certain risks.”
“Can you tell me about those?”
“If you can perform an internet search, I assume you already know most of the risks. Poseys are not a secret, even though people generally don’t like to talk about them. First and foremost, even when used properly, they can restrict movement too much or hold the patient in a position that is harmful to his health. They might struggle and get twisted up the wrong way. Or try to escape the bed and end up hanging himself. Anyone using restraints needs to know the risks and what to do to alleviate them.”
“Are there laws specifying when they can and can’t be used?”
“No.”
“Or how they are to be used? What needs to be done to lower the risks?”
“Nothing legislated, no. It is up to the facility to figure it out. Or the caregiver, if used in a home care situation.”
“And any facility can just make up its own rules?”
Able raised his brows and shrugged. “We have internal policies and procedures to be followed. If we find that a staff member is not following those rules, they are dismissed.”
“No warnings, just gone?”
He nodded. “It is that important. If you can’t follow safety protocols, you cannot work here. No second chance.”
Kenzie wondered if that also applied to nurses who refused to follow quarantine orders. She had never heard what happened to the nurse who had taken Lola to the Halloween Ball and put everyone at risk of contracting an aggressive, potentially fatal virus.
“So you have a policy with regard to poseys?”
“Yes. And any similar physical restraint.”
“And that is?”
“When a restraint is first applied, a supervisor needs to either be inside the room or needs to log bed checks every fifteen minutes to make sure that the restraint is working and is not putting the patient’s health at risk. Does it fit properly? So that they are not able to get around or through it? Is the patient fighting the restraints? Are they in a safe position? What are their vitals? There is a checklist to go through every fifteen minutes to ensure they are safe and well. If they are fighting the restraints, someone has to stay with them. They cannot be left alone.”
Kenzie nodded. That made perfect sense. Those were the people most likely to have adverse health effects. And the most likely to get tangled in a restraint.
“Good. Yeah. That makes sense.”
“After the first hour, if there have been no concerns and restraint is still necessary—often within an hour, the need for the person to be physically restrained has been eliminated—then the checks are made every hour. After four hours, they are lengthened to four-hour intervals. But a patient is rarely in restraints for longer than four hours. And the staff will generally keep up fifteen-minute or one-hour check intervals even when they are not required. It’s up to their judgment, if they feel they are needed more often.”
“Four hours seems like a long time.” A lot could happen in four hours. It was a long time to go between bed checks, unless the patient were sleeping.
“As I said, the staff will often stick to fifteen-minute or one-hour checks. But we rarely have patients in restraints for that long.”
“Then how do you deal with someone who wanders? Who tries to escape or to do something dangerous to themselves or others?”
“Similar to raising children… distract them. Find them something else to do. Talk with them and engage them. Check to make sure that they are not in pain or dealing with a UTI, two things that can cause an increase in agitation. Unless someone is off of their psychiatric meds, we rarely have anyone who is a threat to themselves or others for any length of time. Some facilities won’t use poseys or soft restraints. They consider them too dangerous. More dangerous than the harm that a patient could cause to himself.”
“You don’t agree?”
Able licked his lips and considered it. “I think that, used the right way, they are a beneficial tool. But used the wrong way… used indiscriminately and for long periods of time… the risk is not justified. I would much rather have my residents handled in another way. The dementia ward is a locked ward. Patients cannot simply walk out. You need a key code to get past the doors. That eliminates most risks right there.”
“But some dementia patients are violent.”
“Yes. Sometimes. And if they are consistently violent, we will recommend medications to settle them down. Putting them in restraints long-term causes too much harm. Bruising or even broken bones. Strangling. Ending up in a dangerous position that puts pressure on their diaphragm so they cannot take a full breath. Bedsores. Constipation. Loss of energy and appetite. Better if we can control violent behavior with an antipsychotic or sedative.”
“What about falls?”
“What about them?”
“Don’t poseys and other restraints help prevent patients from falling? I have one patient who would refuse to use his walker and end up falling. So his son used a posey to keep him in bed when he wasn’t there to supervise.”
“Unfortunately, they don’t prevent falls. They just cause other falls. Patients climbing over bedrails or getting pinned between the bedrail and the mattress. Tipping over beds or chairs. Fighting restraints until they are black and blue. It doesn’t stop them from being injured.”
“So what would you recommend for someone like that who was caring for a loved one at home?”
“I would recommend that they get their loved one into a proper care facility where they can be supervised, have a fall sensor, and have medical staff available when needed. I would not recommend that someone susceptible to falls and who refused to use a walker be cared for at home.”
“You said there aren’t any laws about how poseys are to be used in nursing homes. Are there any that prohibit people from using them at home?”
“No. There aren’t. There are no laws restricting their use in any way. Or who they can be sold to. If they could only be purchased by a nursing care facility, that would be one thing. But you can pull up Amazon on your phone right now and have one delivered to your house tomorrow, no questions asked. How you choose to use it is totally up to you, and there isn’t even a warning in the product listings that they could cause injury.”
Kenzie shook her head slowly, thinking about that. Anyone could purchase a posey or another restraint system for use in any situation, without any oversight.
And if something happened, the caregiver could just remove the posey from the victim’s body and dispose of it quietly before the paramedics arrived. And no one would ever know the difference.
Except for Kenzie. Kenzie knew. She couldn’t ignore the mark on Mr. Howard’s throat and pretend that she hadn’t seen it. She now understood what had happened to him and that’s what would go down in her report.
And how to prevent such a thing from happening again in the future? That was another question altogether. With no regulations, no training required, and no warnings about how dangerous restraints could be, Joseph Howard’s death would not be the last that Kenzie attributed to a posey.
16
Dr. Wiltshire stopped at Kenzie’s desk and waited for her to finish what she was typing and look up. Kenzie smiled and nodded.
“What’s up?”
“I’m wondering how you are doing on the Howard file. We really should finish it up.”
“Right. Umm, I just wanted to talk to you about that before drafting my final thoughts on it. I don’t want to waste my time on something that you’re not going to sign off on.”
He lifted one eyebrow. “And why would I not sign off on it? If you have done your job and identified cause and manner of death, there’s nothing for me to do but review your findings.”
“Yes.” Kenzie took her time, thinking about how to best approach her explanation. “I’m sure you will… but I just wanted to make sure. It seems fairly straightforward after the postmortem and talking with Mr. Howard’s son and one of the visiting nurses. It looks like he was put to bed in a posey and, during the night, slid down and was strangled by it. A posey is—”
“I’m familiar with what a posey is. This is not my first rodeo. There was no mention of a posey in the police or paramedic notes.”
“No. That’s the one issue. The son apparently removed it and sanitized the scene before calling 9-1-1. But I have confirmation from the nursing aide that a posey was used regularly to keep Mr. Howard from wandering. He didn’t like to use his walker, and they wanted to keep him from falling down.”
“The nurse says that a posey was in use?”
“Yes. She didn’t say for sure that he was in one that night. It would have been the son that put him down to sleep. But she had instructions to use it during the day when she visited and… left Mr. Howard alone.”
Dr. Wiltshire shook his head, sighing. “Society has reached the point where it is no longer considered okay to leave children or animals waiting in the car while you run your errands. I can only hope that we reach the point at which it is not acceptable to leave a senior who cannot take care of himself alone in your house.”
“Aren’t we at that point yet? If someone called the elder abuse hotline and said that Howard was being left home alone in restraints, wouldn’t they intervene? Wouldn’t Kyle be charged with neglect or abuse?”
“Possibly. But I wouldn’t count on it. He was looking after all of his father’s needs. He wasn’t malnourished or physically abused. And when he died, it wasn’t because he’d been left alone during the day.”
“No, it was because he had been left in restraints at night, with no one supervising.”
“It could just as easily have happened in a nursing home or hospital. None of those facilities would be watching him twenty-four hours a day. He would be left in his room for several hours without intervention. Certainly overnight. Maybe a check-in halfway through the night, but maybe not if he had a bed alarm or motion sensor in his room so they would know he was up.”
“They would not have left him in a posey overnight.”
“You don’t know that. It would not be unheard of.”
Dr. Able had said that at Champlain House, he would eventually be checked on every four hours. That would indicate that a patient could be left in a posey for longer than four hours. Maybe eight or ten or even more. As Dr. Wiltshire said, one bed check during the night to make sure that he was okay. But a lot could happen during the four hours in between.
Kenzie sipped her cold coffee and put it down again. “Okay. I’ll get it written up for you today. It’s already mostly drafted; I just wanted to make sure that you would be okay with me citing it as accidental death, even though we don’t have confirmation that he was actually wearing a posey at the time of his death. There is a mark on his throat, so we know he was wearing or had something wrapped around his neck that was removed after his death.”
“Yes, that’s fine. You don’t have to say it was a posey since we don’t know if that was what he was wearing at the time of death, but you can say that he was known to be restrained by a posey at other times and that he died from strangulation. That you believe it to be accidental.” He gave a slight smile. “You are saying accidental, I assume? Not that the son deliberately killed him by leaving him in a posey?”
Kenzie chuckled, even though she didn’t think it was funny. “No, of course not. I will be saying death by accident.”
“That’s all we need, then. That he died by strangulation, possibly a posey, by accident.”
“Okay. I’ll try to get it done by the end of the day.”
“Good. The family is eager to hold a funeral.”
“Of course.” Kenzie nodded. She knew that not just from the call she had taken from Kyle, but by several messages he had left and an email that he had submitted through the Contact Us form on the Medical Examiner’s Office website. The man was not happy about having to wait for her to finish her investigation. And she had deliberately avoided speaking to him because she didn’t want to deal with his demands and anger over the case not being handled as quickly as he would have liked. She hoped she wouldn’t hear back from him when he realized that she had performed a full autopsy, complete with y-incision. Hopefully, the funeral home would deal with the dressing of the body for the funeral and it wouldn’t be done by Kyle himself. Knowing that she had done an autopsy and actually seeing the sewn-up incision were two very different things, and she was sure he would not be happy about it.
