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Roberta Murphy: She left her nursing home with infected bed sore and later died

An article by Dean Mosiman as it appeared in the Wisconsin State Journal on November 6, 2007:

She didn't die happy," Richard Mason said, caught between anger and tears as he gazed at his grandmother's grave.

"That's the bad part. She didn't go away happy."

Roberta Murphy died at age 83 after suffering for weeks with a bedsore the size of a man's hand on her backside. The painful, open sore appeared during a relatively brief stay at what was once one of the state's worst nursing homes: Havenwood Nursing and Rehabilitation Center in Milwaukee.

The state attorney general's office eventually raided Havenwood, and the state closed the six-story facility in late 2005. But that came about a year too late for Murphy.

The state Division of Quality Assurance, which oversees long-term care, had found problems at Havenwood but was trying to force the owners to shore up the place, not close it. In the end, it took the state attorney general's office to bring down the hammer - an unusual move, acknowledged William Hanrahan, who led the raid as an assistant attorney general and now serves as a Dane County Circuit Court judge.

"This was not a nursing home inspection," said Hanrahan, who was there. "It was a crime scene."

In May, Murphy's estate sued Havenwood and its owners, who have denied any wrongdoing or liability. And in August, the attorney general filed criminal charges against one of the owners. Attorneys representing the defendants declined comment or could not be reached.

Otis Woods, director of the state Division of Quality Assurance, said inspectors try to improve conditions at facilities before imposing penalties. But Havenwood, he said, has taught the agency to become more aggressive.

Havenwood, Woods said, "was a learning experience."

Loving grandmother

Murphy, who spent most of her life in Paducah, Ky., and Milwaukee, worked as a certified nursing assistant. She was a stabilizing force for her family, her grandson said.

Big smile. Big hardships. Big heart.

"She would give her last dime, her last quarter to help someone," Mason said. "She was kind. She was loving. She would talk with anybody. She loved kids, loved to be around them. She didn't ask for nothing."

Mason said his parents' household was troubled by drug abuse, so he was "always with my grandma."

"We would drive everywhere," he said. "We'd take long trips, just driving. We'd just get in the car."

Started with a fall

In old age, Murphy's health faltered. She was diabetic and had kidney problems, but she still managed to live on her own - until she fell on May 25, 2004.

Six days later, suffering from weakness in her legs, incontinence and back pain, Murphy was taken to a hospital.

A few days later, on June 5, she was admitted to Havenwood, a 288-bed nursing home in Milwaukee, for what was supposed to be short-term rehabilitation.

Havenwood records indicate Murphy had no bedsores the day she was admitted, said attorney Jeffrey Pitman of Milwaukee, who is representing Murphy's estate in a lawsuit against the nursing home, its management company and others.

Within 10 days, serious sores had begun to appear, Pitman said. By the 13th day, she had a Stage 4 pressure ulcer - the most serious class of bedsore - in the flesh below the base of her spine.

Bedsores occur when a patient is allowed to remain immobile too long. Unrelieved pressure cuts off the blood supply and tissue dies.

"If she's being turned and being ... taken care of, that's not going to happen," Pitman said.

'She wanted to be out'

After a short time at Havenwood, "she was in so much pain. She was crying. She wanted to be out," Mason said.

Staff members promised to help her, he said.

On June 28, Mason got a call saying his grandmother had been hospitalized. He rushed to see her.

"There was this smell," he said. "It was the bedsore. They let it get infected. I've never seen anything like that in my life. You could see her bone.

"I cried, I cried. I threw up," he said. "I was angry. I just wanted to fight everybody."

The nursing home, Pitman said, had given her a lot of pain medication - an overdose - and ignored her request for a doctor.

Doctors said Murphy needed dialysis for her kidney condition, but she refused, fearing it would mean she'd be returned to a nursing home.

"After Havenwood, she was just done, she wouldn't fight it," Mason said.

On July 9, Murphy was moved to another nursing home and, 20 days later, she was admitted to a hospice. She died on Aug. 4, 2004, of a urinary infection related to kidney failure.

"She was very strong," Mason, 30, said. "She suffered from the time she went to Havenwood until the time she passed away. "I'm a young man. I would never have lasted that long."

"This was," Pitman said, "absolutely preventable."

Havenwood's troubles

Although Mason didn't know it, Havenwood had been struggling to meet standards for quality of care, staffing and finances.

The extent of the problems are laid out in an April 8, 2005, affidavit to support a search warrant used by the attorney general's office in the raid.

The affidavit chronicles whistleblowers' tips about an array of problems - some dating to 2002 - of residents with bedsores, residents having sex or wandering from the facility, insufficient staff and training, and "widespread neglect." Residents got served peanut butter and jelly sandwiches for all meals for a week. Oxygen-supply units and washing machines were broken.

The state Division of Quality Assurance had found problems and was trying to get owners to address them. In late 2004, the state division inspected Havenwood several times, ordering corrections and issuing citations. In January 2005, an unsupervised resident diagnosed with psychological problems jumped from the fifth floor to his death. A March 2005 inspection found even more health violations.

Havenwood, however, was never designated as having a substandard quality of care. Substandard means residents are in immediate jeopardy, exposed to a pattern of widespread harm, or potential for widespread harm. A long pattern of substandard quality of care may lead to designation as a "special focus" facility, meaning greater oversight and even federal decertification.

Raid, then shutdown

On April 13, 2005, the attorney general's office and nearly 50 state and federal agents raided the facility.

But it wasn't the state's inspection system that sparked the action. Havenwood staff members had contacted the state attorney general's office. An investigator, stunned by their accounts of abuse, took action to obtain a search warrant.

Employees, including some who had blown the whistle on the facility despite fear of losing their jobs, discreetly expressed gratitude during the raid, Hanrahan said. The state took control of Havenwood in May, hired a contractor to operate the facility while patients could be relocated, then closed it in the fall of 2005.

Havenwood, owned by Karen E. Mason of Chicago and Leo Feigenbaum of Lincolnwood, Ill., is an extreme example of "what's wrong with our nursing home industry," Pitman said.

In May of this year, Pitman filed a lawsuit on behalf of Murphy's estate against Havenwood, Mason, Feigenbaum and others alleging Murphy suffered a loss of dignity, severe pain, mental anguish and wrongful death. It seeks compensatory and punitive damages and other relief.

And in August this year, state Attorney General J.B. Van Hollen charged Mason, 55, with stealing tens of thousands of dollars from resident accounts and neglecting residents between 2002 and 2005. If convicted, she faces penalties of up to 19.5 years in prison and a $30,000 fine. The investigation is continuing, Van Hollen spokesman Kevin St. John said.

Attorney Laurie McLeRoy, of Milwaukee, who represents Havenwood, declined comment. Craig Albee, of Milwaukee, who represents Karen Mason, did not return a call.

Richard Mason, Murphy's grandson, blames Havenwood and the Milwaukee County social service system, named as defendants in the lawsuit, that put his grandmother there. Because she had scant resources, Murphy had to go to a place that accepted federal Medicaid patients. Attorney Nadya Shewczyk, who represents the county in the case, declined comment.

Now, Mason visits his grandmother's grave to escape frustrations of the day or "just to chit chat." But he remains haunted by memories of Havenwood - and her suffering.

"It was like nobody cared," he said. "She was an older person. She was going to pass away anyway."

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