Alone and unsupervised, the 90-year-old woman wandered up and down a second-floor hallway of the assisted living facility.
A video recording would later show Bonnie Walker walking the hall for several minutes in white tennis shoes, holding her purse. She wanted to go home.
The staff knew she had dementia, and there was a plan in place to move her into a unit that would better meet her needs. In the meantime, she was to be watched around the clock. But after midnight on July 27 last year, no one was keeping an eye on Walker, according to state documents.
No one noticed when a door's security bell chimed at 12:15 a.m.
Seven hours later the staff at Brookdale Charleston called her family. According to a police report, a Brookdale program coordinator thought she saw a body in a pond near the facility. She was on the phone when she looked down into the shallows and saw a human arm. Walker's body was found soon after on the other side.
Later, investigators said they believed Walker fell into the water, attracting an alligator’s attention.
Department of Health and Environmental Control investigators found the facility staff did not follow their own guidelines to conduct night checks on Walker, a plan put in place when she had wandered off before. She had left the facility days prior "looking to go home," and staff decided she needed to be housed in a memory care unit.
Now Brookdale Charleston could be facing enforcement action from DHEC. Representatives of the facility met with state officials June 13. A spokesman for DHEC said the two parties are "working on finalizing a consent order." Brookdale declined to comment on the matter.
Such meetings are an opportunity for a facility to present any evidence of their own, said Pam Dukes, formerly a health regulator with DHEC. It would be “very unusual” for the negotiation not to end in enforcement, Dukes explained, which could mean a fine or a license suspension.
Repeated complaints
The action stems from several visits to the facility by DHEC inspectors since Walker’s death. Investigatory records show Brookdale Charleston's problems extend beyond that incident. A public records request shows DHEC has followed up on 15 complaints directed at Brookdale Charleston since 2013, alleging: the facility accepted people beyond its capacity to serve, that response times to resident calls were poor, that necessary records were not kept and that medications were not given correctly.
Eight investigations ended in a citation. Each time the facility gave DHEC a “plan of correction.”
In January 2013, the 100-bed facility was found to have admitted at least three residents who were beyond its ability to care for. When a resident wandered from the facility twice in one day, the site could not prove to DHEC that police were called, records state.
In some instances, DHEC found insufficient evidence to support complaints. In other cases, their findings seemed to prove the facility was fulfilling its promises through documentation. Outside complaints of the facility being short-staffed were repeatedly found to be false, records show.
Of the more than 20 facilities owned by Brookdale in South Carolina — the largest assisted living company in the U.S. — the Charleston home is the only one currently facing an enforcement order from DHEC, department spokesman Robert Yanity said. The potential order is also the facility’s first, he said.
Heather Hunter, a Brookdale spokeswoman, said the company could not comment on discussions with DHEC or pending litigation.
Walker’s granddaughter has filed a personal injury suit against the facility. Two other suits have also been filed against the home in the past year. Nathan Hughey, lawyer for the plaintiffs in the other cases, said Brookdale Charleston will keep residents beyond their ability to properly care for them.
“They’re keeping them in until something bad happens,” he said. “I think they know they can’t take care of them.”
'Not just paperwork'
Assisted living facilities, unlike nursing homes, are not equipped to offer round-the-clock medical care. But they still have to tend to the safety of their residents, and DHEC is tasked with ensuring they are doing so.
Dukes was with DHEC for 28 years, most recently as a deputy director overseeing the regulation of health care facilities. About half of the meetings, such as the one Brookdale had in mid-June, are with assisted living facilities, Dukes said. DHEC regulates more than 400 assisted living facilities in the state.
She explained the facilities that most often had problems were smaller and accepted Medicaid. Brookdale Charleston is private-pay only. Larger facilities like Brookdale’s generally had better compliance, she said.
Still, Dukes, who left DHEC in 2013, said facilities don’t always discharge residents when they should.
Facilities are required to make care plans and update them every six months. Dukes said failures to keep those plans up-to-date were common. She said those plans are important because they show when a resident begins to require more care.
“It’s not just paperwork,” Dukes said.
Brookdale not alone
Brookdale Charleston is not the only assisted living facility with recorded lapses in care for its residents.
Protection & Advocacy for People with Disabilities is a nonprofit organization with the authority to conduct unannounced inspections at assisted living facilities across the state. In the more than 200 inspections they have done since 2015, many document instances of filth, maintenance problems and poor record-keeping. Of the 10 biggest facilities Protection & Advocacy checked, only one had no issues with resident care plans. In almost every case, medications were sometimes missing or were incorrectly administered.
Dave Zoellner, managing attorney for Protection & Advocacy, said such issues are common. Some problems are harder to identify, however. Whether facilities are improperly allowing residents with cognitive decline to wander is difficult to say, he said, because residents are supposed to have freedom of movement. Some things are clearer cut, though — the nonprofit's inspector repeatedly recorded the smell of urine and feces, even at the state's biggest facilities, for example.
Rhoda Jones alleges staff at Brookdale Charleston failed to bathe her mother-in-law for six months. She didn’t doubt they kept a care plan for her in-laws, she said, she just doesn’t think they were following the plan.
Her mother-in-law, who is 95, told her family after some time she was only sponging herself off to keep clean. She hates the hassle of bathing. No one at the facility would force her to bathe, Jones said.
"Nobody ever seemed to check on them," Jones said.
Jones' 93-year-old father-in-law has dementia and could have easily wandered off, she said. She said the front door to the facility was never locked. Because her in-laws have each other for company, she added, they rarely wander off.
Jones did not file any formal complaint, but opted to move her in-laws to Ashley River Plantation, another assisted living facility located on nearby Ashley River Road. Brookdale declined to comment on her allegations, citing client confidentiality issues.
Jones said her family initially liked Brookdale's facility because it seemed clean and high-class. She didn't expect something as simple as cleanliness and unlocked doors to be a concern.
"We didn't know any better," she said.
