Nick Alexander was visiting his stepfather Aug. 28, 2016, at Carlton Senior Living, an assisted living facility in the Sacramento suburbs. He was concerned about Alan Nelson, who had fallen numerous times at the facility, and Nick Alexander was frustrated that no changes were being made.
Nelson’s doctor prescribed the placement of alarms on his wheelchair and bed to alert staff at the facility when he was up and to reduce the potential for a fall. But no alarms had been installed, even though the family asked for them repeatedly.
So during that visit in August, Nick Alexander asked the director of his stepfather’s care unit when the alarms would be installed. He was assured a staff member was working on it and placement would be immediate.
Just hours after the meeting, Alan Nelson had his most devastating fall.
“Four hours later, there was a message on my phone saying Alan had had a really bad fall,” Alexander said. “And that’s in the death certificate — the injury (from) that fall, to Alan’s skull and brain — is listed as one of the contributing causes of his death.”
He suffered fractures to his left frontal skull and left nasal bone and had a brain bleed, according to state documents.
Nelson died, at the age of 76, five weeks later.
Angered by the care his stepfather had received at the facility, Nick Alexander and his mother filed a complaint with the state. That led to state findings that Nelson had 21 unwitnessed falls and three witnessed falls in 12 months.
“There were a number of falls (Carlton) didn’t even report to us; we only found out about them from the report from the state,” Alexander said. “We didn’t know that there were nearly as many falls as there were.”
An investigation by the California Department of Social Services concluded that the facility had failed to provide proper and necessary care and supervision, resulting in numerous falls and subsequent injuries.
Ultimately, the state decided to issue an enhanced penalty of $10,000.
Lisa Schumann, Carlton’s regional vice president of operations, responded to the penalty with a statement.
“Carlton Senior Living has been providing seniors with high quality care in a home like environment for more than 30 years,” the statement reads. “We are committed to protecting residents’ privacy and as such cannot comment on a particular resident’s care. We value our relationship with the Department of Social Services and share DSS’s commitment to improving the health and safety of our residents.”
According to the department’s website, Carlton Senior Living, formerly Carlton Crown Plaza, has received nine Type A citations, for placing an individual’s immediate rights, safety or health in jeopardy, and 10 Type B citations, for impacting an individual’s rights, safety or health.
The majority of the Type A and B citations issued by the state are the result of investigations conducted in response to complaints.
Alan Owen Nelson
Alan Owen Nelson was born in a small town in Minnesota and is described by his family as a kind, friendly and gentle person. He worked as a salesman and liked to tell jokes and play tennis.
Described as an athletic person by his wife, Dr. Sharon Alexander-Nelson, Nelson began to notice that even though he would workout, he couldn’t get stronger. He became breathless going up stairs and he had low blood pressure and would get dizzy and fall.
After he was diagnosed with Parkinson’s disease and dementia, his wife determined she could no longer provide her husband with the care he needed, and she thought Carlton was the best solution.
The assisted living facility is off Fulton Avenue in the Arden Arcade area of Sacramento County, just two blocks from the couple’s home, and Sharon Alexander-Nelson visited her husband of 36 years nearly every day. He moved into Carlton in September 2015 with a note from his doctor: high risk for falls.
Over the course of his stay there, Alan Nelson lived in three different living areas within the facility. He started out in an assisted living unit in the front.
“He seemed to be all right, he had friends there and there were things for him to do,” Alexander-Nelson said. “He did what he thought — that I thought — was the best.”
At home, Alan Nelson could use a railing to get out of bed. But at the facility, that wasn’t allowed.
“They had rules that I didn’t understand,” Alexander-Nelson said. “But they were supposed to take care of him carefully and we paid a lot of extra money for that.”
As Nelson’s care became more advanced, the financial cost to his family increased. Generally, long-term insurance provided around $4,000 a month. In addition, the family paid an estimated out-of-pocket cost of $4,000 every month.
Documents both obtained by The Bee and posted online by the California Department of Social Services’ complaint investigation show Nelson had four falls in 92 days between October 2015 to January 2016 resulting in abrasions to his scalp and head, neck and side pain.
Then, from early January to late February, he had five falls in 52 days, resulting in bleeding and abrasions to his head.
Department documents say Nelson’s nurse had suggested a number of possibilities to lessen the impact of a fall: “bed/wheelchair alarm, pendant alarm, assessment of possible causes of frequent falls, providing supervised and assisted ambulation, 24-hour personal caregiver” or a “protective mattress on the floor.”
The department found Carlton didn’t do anything.
‘A fall issue’
Nelson had a bad fall in early May and was found unresponsive on the floor of his room. He was treated at UC Davis for a head injury. After, he had a brief stay at Sherwood Healthcare Center, a skilled nursing facility in Sacramento. At Sherwood, he was confined to a wheelchair that was equipped with an alarm.
“He was very unsteady on his feet,” Alexander explained. “And they were concerned about him falling.”
Sharon Alexander-Nelson said her husband had liked Carlton, and she wanted him to move back.
When he returned to Carlton, he moved into a new unit called Crown Enhanced Assisted Living. The staff said he couldn’t have alarms in the facility, as the doctor ordered, but said they had “other means to handle this,” Alexander said.
According to department documents, the executive director of the facility said alarms were not allowed “because the facility could not guarantee that the alarms would be heard by staff members.”
During Nelson’s time in the facility, from June to August, there was, as Nick Alexander referred to it, “a fall issue.”
Alexander said he knew about only one or two falls his stepfather had while in this facility, but department documents show there were far more.
The documents show Alan Nelson had four falls in 11 days from July 7, 2016, to July 18, 2016. Then there were two falls in four days in late July to early August.
Nine falls in 21 days
The staff at Carlton said they would be better able to monitor Nelson in the Memory Care Unit. In that facility, he could have the alarms his doctor recommended.
He moved into the new facility in late July.
In late August, Alexander spoke with his stepfather’s neurologist and said the family had been waiting three or four weeks for Carlton to set up alarms on the bed and wheelchair.
“She said, ‘You shouldn’t have to wait,’ ” Nick Alexander recalled. “So we left a message with the director that we wanted those alarms.”
Alexander-Nelson said she and her family were nagging staff to install the alarms – “it was maddening.”
In late July, Carlton removed a rug from Alan Nelson’s room’s hard floors because they were “updating,” Alexander-Nelson said. The rug would have provided an amount of cushion in the event of a fall, Alexander said.
“This, despite the fact that one of the main reasons Alan was moving into the Memory Care Unit was due to the urgency to respond to a high fall risk,” Alexander added.
The following Sunday, Alexander was checking in on his stepfather when he ran into Schumann, who promised him a staffer was placing the alarms immediately.
Hours later, Alan Nelson fell and hit his head on the floor of his room. State documents report he suffered facial fractures and a brain bleed. He was diagnosed with pneumocephalus, the presence of air in the cranial cavity, fractures to his left frontal skull and left nasal bone and “hemorrhagic contusion or bleeding of the brain.”
A CT scan showed a “blood clot in the left frontal lobe, small amount of air or gas in the left frontal region and fractures on the left frontal bone and left cheek bone.”
He was sent to the ICU at Mercy San Juan. His stepson and wife made arrangements to move him from Carlton into a smaller facility, which promised better care, but he died at Mercy San Juan in early October 2016.
Department documents show he had nine falls in 21 days in the month of August 2016, causing bleeding in his left eye, “swollen and scant yellow discharge, right eye red and swollen.” He was “found in (a) pool of blood.”
According to state documents, his cause of death is listed as “acute respiratory failure, septic shock, bilateral pneumonia with other contributing conditions as subdural hematoma.” The subdural hematoma was blood that collected between the surface and covering of the brain after he fell and hit his head.
Sharon Alexander-Nelson said her husband’s death still haunts her.
“I feel terrible guilt and remorse that I didn’t catch onto this more quickly,” she said. “It’s like I never understood. I think I was sort of intimidated by this whole medical (system). I wanted to believe it was a good place. I question my own ability to have protected him and I can imagine a lot of people feel the same way.”
After her husband’s death, Alexander-Nelson and her son decided to file a complaint, but “had no idea how it would be done,” Alexander said. They came across an article published in The Sacramento Bee about issues with care provided by nursing homes and learned about the Foundation Aiding The Elderly.
FATE is a Sacramento-based organization that helps families deal with long-term care facilities. Carole Herman, the founder of the organization,
filed a complaint about the circumstances surrounding Nelson’s time at Carlton on Feb. 14, 2017. She received the results of the state’s investigation this past May.
According to those findings, Carlton “failed to provide further intervention to prevent further falls and injury.” The facility’s failure to provide the proper care and supervision “resulted in multiple repeated falls with injuries.”
Herman said she was frustrated the department took over a year to release its findings. “I’m a believer in justice delayed is justice denied,” she said.
Michael Weston, the deputy director of public affairs and outreach programs with the Department of Social Services, said the report followed “an extremely complex and important investigation. The department conducted interviews, reviewed numerous documents and obtained medical records.”
Herman, however, feels there may have been serious ramifications to what she feels was a delay by the state.
While she was waiting for the state’s findings, she filed a separate complaint about an 85-year-old patient who fell on 20 separate occasions, resulting in “an open lesion in back of his head.” He was also a patient at Carlton.
“If you had expedited this complaint, perhaps this other client would not have been injured,” she said. “It could’ve prevented this other man from dying.”
A complaint investigation report posted on the department’s website in July details the case of a patient who suffered multiple falls resulting in injury.
“Facility staff neglected resident resulting in stage 3 pressure injury,” the report concludes. “Facility has insufficient staffing to meet resident needs.”
On Friday, Aug. 24, the department issued Carlton a civil penalty in the amount of $10,000, “warranted for serious bodily injury” caused to Nelson.
“It’s not nearly enough for what happened to that man,” Herman said.
According to Weston, the state developed a plan of correction, including an in-service, two-hour training to be conducted by an outside agency to address “proper observation and monitoring of residents and a statement verifying procedures were in place to adequately re-assess residents with significant changes in condition. “
A signed training log was required to be submitted to the department of Social Services’ community care licensing division by June 30. Weston said the plan of correction was cleared on July 12.
It’s difficult for Sharon Alexander-Nelson and her son to talk about Nelson’s time at Carlton.
“What did I learn? I ask myself that,” Sharon Alexander-Nelson said. “Stay out of hospitals if you can, and stay home if you can get help in the house. The repercussions on the loved ones … they’re very severe.”