Five years ago today.

This time five years ago, I was excited that Mom was going to be discharged from Hendersonville Health and Rehabilitation. She had been getting stronger and it finally seemed things were getting better. My wife and son had taken Mom out to get herself ready to go home. She went to the bank, and to Walmart for a new outfit to wear home. She was in good spirits and looking forward to leaving "that place". She was scheduled for discharge on November 3, 2011.
On the morning of November 3,2011, I received a phone call at 5:07 am. I was already awake and getting ready for work. The voice on the other end of the phone told me that there was a problem and that Mom was not breathing. She said they were working on her and that I should get there as soon as possible. I finished getting dressed and drove there as fast as I could. I had no idea things would turn out the way they did. When I arrived there was a Blue Ridge Fire and Rescue truck out front.
I had to ring the bell and a younger woman let me in and directed me to the desk that was right across from Mom's room. It was eerily quiet and there was one nurse behind the desk, and no one else in sight. The nurse told me that they had taken Mom to Pardee Hospital and that she wasn't responding. Her name was Tammy Mace and it turns out that she was the one who found Mom unresponsive in her bed.
I drove to Pardee Hospital as fast as I could, not knowing what to expect. When I got there,an ambulance was taking someone into the ER. I went to the desk and was told they had just brought her in. I was directed to sit in the waiting room. I called my wife and she and my son headed that way. A nurse came and took me back into a room with a couch and chairs. I was told that Mom had not made it. My wife and son showed up and I had been calling my brother and sisters to let them know what happened. Soon the whole family was there.
The story was that the nurse at Hendersonville Health and Rehabilitation had walked by the room and saw Mom slumped over in her bed, she called out to her and when she didn't answer went in. According to the records she called for help and got Mom ready and started C. P. R. There was no defibrillator on site. The paramedics showed up and continued C.P.R, along with other medication.
That is how this all got started, I had no idea what I was getting into. I began at the hospital, where they had no records at all. The records were all at Hendersonville Health and Rehabilitation. Something just didn't seem right so I started looking at obituaries, and there seemed to be way too many from Hendersonville Health and Rehabilitation.
As time went on I learned that the ER doctor did not sign the death certificate. That seemed strange as he was the one who pronounced Mom dead. The doctor that signed her death certificate was Dr. Larry Joe Russell. No one in the family had ever seen or met Dr. Russell. According to the records he was Mom's Dr. on record at Hendersonville Health and rehabilitation.
Things just kept getting stranger and stories didn't seem to match. I had finally gotten the records from Hendersonville Health and Rehabilitation and they were full of mistakes. They actually had the wrong room number on the records. I'm not sure they knew what patient was in what room. My brother and I filed complaints with NCDHSR, and the fight began.
I had been doing research as to how they determined the cause of death. According to the NC State Medical Examiners office, if someone dies in a nursing home from something they are not being treated for, they are supposed to do an autopsy. There is a stipulation regarding the age of the patient, but there is no specific age. According to Dr. Russell, Moms poor health and age were explanation enough. Keep in mind they were discharging Mom due to her reaching her goals and improved health. I requested an autopsy from the local coroner and was denied. I then called Dr. Russell and he said he would see what he could do, I never heard back from him.
I called the NC State Medical Examiners office several times. One of the discussions I had with them I revealed that Mom had fallen a couple of days before. That was enough to get their interest up and they requested the record of the fall from Hendersonville Health and rehabilitation. That's where it gets really suspicious. The records stated that nurse Lara Mooney LPN had witnessed the fall. The strange thing is that the record of the fall was dated December 2011, a month after Mom's death. It was faxed somewhere the day it was created. I am assuming that is what was sent to the Medical Examiner.
The family had gotten close to Mom's roommate, and my sister called her to get her version of what happened that night Mom fell. According to her, she woke up to see mom lying in the floor. She then pushed the call button and waited for someone to help. Eventually she heard people talking in the hall and called out to them. The CNA's called the nurse on duty, Lara Mooney who came in and told them to check her blood pressure and get her back in bed. The roommate then swore to her statement and had it notarized.
Over time, I discovered that Dr. Larry Joe Russell was one of the owners of Hendersonville Health and Rehabilitation. He was instrumental in organizing a group of local doctors to buy it From Pardee Hospital. After looking further into it, there were a couple of doctors on the papers but there were also others. My brother and I started looking into the whole thing and kept seeing the name Christopher Sprenger on documents, he was the registered agent with the Secretary of State. Turns out that Christopher Sprengers family owns a chain of nursing homes in Ohio. Mr. Sprenger and his partner Michael Deloach have bought lots of nursing homes in North Carolina.
As the search continued, we found out that the owners of the pharmacy providing the meds for Hendersonville Health and Rehabilitation were also part owners. The group is making quite a living off of Medicare dollars. Dr. Russell is the number one Family Practice biller of Medicare in the State of North Carolina. Several of his FNP's and P.A's are in the top five billers as is Blue Ridge Pharmacy, the other owners. All of this doesn't seem to alarm the people that oversee nursing homes like the NCDHSR or Centers for Medicare and Medicaid services.
This is just a small portion of what I know today that I wish I didn't. I find it hard to write about this but people need to know what happens in nursing homes, especially Hendersonville Health and Rehabilitation. More to come.

The end of the Quest: Not today!

Since my youth my father taught me to fight when I knew I was right. I have been fighting for over four years now, and I am tired. I have spoken to agents from the FBI , OIG , CMS, DHHS, DHSR and two congressmen. I have been told that I have enough to warrant an investigation. Yet not one single agency has acted. I refuse to let this stop me. I definitely feel discouraged at times and even slow down
I have spoken to countless people who have experienced similar wrongs. I have heard stories from people whose parents have been dropped, poisoned, beaten and raped in nursing homes. Of all of these, none would stand up for those who couldn't. They will email or call to tell their horror stories, but that's as far as they will go. I am not sure what they are afraid of, other than the fact that Dr.'s can kill people and get away with it!
I probably sound a little crazy to most people, but think about the last time you went to your doctor. Did they seem like they knew your medical history, or did you even see a doctor or was it a PA. In North Carolina almost all doctors are now part of a " system " that is associated with a university, or private hospital. It is virtually impossible to find an independant provider. It benefits them to have lots of tests and write lots of prescriptions. It is basically a monopoly that at one point not long ago would have been illegal.
The agency that regulates nursing homes is the NCDHSR which is part of the NCDHHS. Most of us have heard the horror stories of what happens to children that are supposed to be protected by the DSS which is also part of this family. How many times have you seen the news where one of the protected children is killed or seriously injured while being " protected "? Even worse how many times have you heard a story of something terrible happening to a child that the DSS didn't feel was at risk?
When it comes to the elderly, you never hear any of these stories. Do you suppose it is because the nursing homes don't make mistakes? Is it possible that there are never any accidents, medication errors or abuse? The bottom line is that the NCDHSR is negligent in their inspection process. In almost every case that someone files a complaint, the NCDHSR cant seem to find that the nursing home violated any regulations. Just as an example, from 2011 till 2016, there were a total of seventeen complaints filed against Hendersonville Health and Rehabilitation. Of the seventeen the NCDHSR was only able to find two substantiated complaints, thats two out of seventeen.
The process of filing a complaint is complicated. First they try to get you to go to the ombudsman in order to solve the complaint. All the ombudsman can do is provide training, they have no legal authority. Next if you are persistent the NCDHSR will take your " anonymous "complaint. In my case the nursing was told that it was I who complained. Then an inspection team made up of nurses and other industry " professionals " will show up at the home. They go to the administrator's office and announce themselves. The administrator then announces to the staff that the inspectors are on site. This is standard practice and is allowed according to NCDHSR rules. If you ever happen to be in a nursing home during an " inspection ", you will see the entire staff running from room to room fixing things. The last time I was at Hendersonville Health and Rehabilitation there was actually a sign on the front door informing everyone that there was an inspection going on.
This is an example of why the system doesn't work. If you have ever been in a nursing home I'm sure that you noticed at least one thing that made you wonder. Did I really just see or hear what I thought I did. Think about it!

The quest continues , Chapter 4 The nurses and staff of Hendersonville Health and Rehabilitation

This should have been chapter one, it was actually the beginning of the whole thing. They call them nursing homes for a reason.
Hendersonville Health and Rehabilitation is like most nursing homes, they have an administrator, a director of nursing and an assistant director of nursing. The administrator was Cookie ( Maude ) Romeo, the director of nursing was Susan Habel RN, and the assistant director of nursing was Anette Corn RN. I had the misfortune of having to deal with each one of them.
Ms. Romeo was all business, she had no compassion at all. When I met her I was trying to obtain a copy of Mom's medical records from Hendersonville Health and Rehabilitation. She tried to refuse my request, but being that I was the legal administrator of Mom's Estate , she had no choice. The first set of the records was copied by the medical records clerk, but when I showed up to get them, she said that they were sending them from the corporate office. The clerk , Jennifer Thomas had copied them already, but she said Ms. Romeo did not want me to have that copy. I asked Ms. Thomas why she could not provide me the ones she had copied and her reply was that Ms. Romeo did not want her to waste the paper! She had already printed them, but Ms. Romeo found out that she was going to give them to me, and stopped her. I would guess that those records would have told the real story of what happened to Mom. The set of records I have were sent from the corporate office, which is two exits away on the interstate. It took over three hours for them to get to me. I wonder what records they changed in those three hours. My suspicions began to grow every time I spoke to a representative of Hendersonville Health and Rehabilitation. Once I got the records I can understand why they were trying to keep them from me.
Annette Corn RN was the first person I spoke to after Mom passed. I'm sure her job was to make you feel like the staff was devastated by the loss of your loved one. When I asked her what exactly happened the morning Mom died, she actually called the nurse that was on duty that morning. Tammy Mace RN was the one who found Mom in her bed that morning. The whole time she was telling me about what had taken place, she never looked me in the eye. She mostly stared at the floor the entire time. Not what you would expect from a person who was telling the truth. Her story only added more confusion as to what actually happened. As I told the story to my brother and sisters that afternoon, it only added to the list of questions.
The next member of the compassionate nursing staff of Hendersonville Health and Rehabilitation that I had the pleasure of meeting with was Susan Habel RN. Ms Habel was the Director of nursing while Mom was a patient there. Our meeting was not quite as cordial as the meeting with Ms. Corn. As soon as I started asking questions, Ms. Habel got down to business. According to her the staff had done a great job that morning. She went so far as to tell me that the EMS crew that responded, had complimented the staff on how they handled the situation. Next she asked me if Mom's body was still warm when I saw her in the Emergency Room at Pardee Hospital. That was pretty much the extent of our conversation, Ms. Habel then took me to Cookie Romeo's office. Obviously I was not going away and it was now up to the front office to deal with me. Ms. Romeo basically informed me that I was not welcome there and it was time for me to leave.
In the mean time we had been going through the hundred plus pages of Mom's medical records. The one thing that stood out the most was the MAR's ( medication administration records). First of all they had the wrong room and bed number on them as did most of the records in the file. There was also an issue with a prescription for Ativan. It seems that Mom had gotten upset one afternoon and asked for something to calm her down. The nurse on duty that afternoon and evening was Lara Mooney LPN. Nurse Mooney filled the prescription and according to records and family members she administered one dose that evening.
Early the next morning, Mom fell in her room. When I visited that morning, Mom made a joke about the fall. However she had a bandage on her right arm. The staff advised us that Mom had fallen, but never any detail about the fall. Turns out that Lara Mooney LPN was the nurse on duty at the time Mom fell.
This is where things got really suspicious. According to Lara Mooney, she had actually witnessed the fall. Her statement was that she was standing at the foot of the bed as Mom removed her personal alarm and slid to the floor before she could get to her. That means that at three in the morning, Mom was able to reach up and remove a clip on alarm and attempt to stand up before nurse Mooney could take the three or four steps to stop her. Hard to believe that while still under the effects of the Ativan, and with poor vision, Mom was able to accomplish this.
The only account of this was a late entry in the nurses notes, dated a month after Mom had passed. This version of the story was never told to the family after the fall. It also does not come close to the story told by Mom's roommate at the time. According to the roommate, she was woken by Mom's voice asking for help, while lying face down between the beds. The roommate stated that she pulled her call cord and waited for someone to help. She said that after several minutes she saw two CNA's walk by. Although the call light was on, she had to call out to them to get them to respond. They entered the room and called for the nurse on duty. Lara Mooney LPN came into the room and told them to take her vital signs and get her back in bed.
It turns out that Lara Mooney LPN, had been disciplined by the NC Board of Nursing before. She was actually cited for practicing nursing without a license. At the time she was working for Hendersonville Pediatrics. It appears that nurse Mooney likes to work with the most vulnerable of all patients, the children and the elderly. It's no surprise that she was able to get a job at Hendersonville Health and Rehabilitation. They like to hire the ones that really need work, and will do whatever thay are told to keep their job.

The Quest Continues - Chapter 3 the OIG

The OIG (Office of Inspector General ) is responsible for enforcement of the DHHS laws including Medicare Fraud. Their mission statement is to " Protect the Integrity of the DHHS ( Department of Health and Human Services ) programs.
In the beginning we were reaching out to everyone we could, trying to get representation. In an odd phone call my brother was speaking to an agent with the DEA ( Drug Enforcement Agencey ) regarding the missing medication and the false records. During the conversation, it was suggested that my brother contact the OIG. The DEA agent had a connection at the OIG and passed the information on to my brother.
During this time I was reaching out to the NC State Medical Examiners Office in regards to having an autopsy done. The Medical Examiners guidelines states that an autopsy is to be preformed if a patient dies in a medical facility, from something other than they are being treated for. Mom's situation fit into that category, and there were no tests done at Pardee Hospital. The cause of death was listed as acute coronary arrhythmia , with no contributing cause. The death certificate was signed by a Dr. Larry Joe Russell. Dr. Russell had never actually seen Mom but he was listed as her doctor. A Dr. Boleman was the ER doctor who saw Mom the morning she passed.
My brother had made contact with the OIG office and he requested we send him all our information and any evidence we had collected. We spent a great deal of time assembling a packet for him to review. My brother put the packet in the mail and notified the agent, David Lange that it was on the way. Agent Lange said he would review the packet and would be in touch.
It seemed that agent Lange was really interested in Dr. Russell and all the stuff he had his hands in. When we started our search Dr. Russell was involved in at least six separate offices, a lab , an oxygen supplier , a sleep clinic and Hendersonville Health and Rehabilitation. He was also supervising a Dr. who was in trouble for over prescribing, and another physicians assistant who was reprimanded by the NC Medical Board for operating an office without a license . I guess there is something to be said about the friends you keep.
Agent Lange confirmed that he had received the information, and would begin his review. Again we experienced a sense of relief. The authorities were finally willing to do their job. After some time my brother contacted Agent Lange to pass on some more current information. Much to our surprise the agent said that his office was understaffed and he had spoken to the FBI agent that we had contacted. He stated that he was going to leave this in the hands of the FBI. We later discovered that he had never even contacted the FBI, and had made no effort to do his job.
Every time we start to believe there may be some hope that the Federal and State authorities are going to actually do their job, another disappointment. Still there is no way to get around the influence of the wealthy owners of the nursing homes and pharmacies.
My brother and I have made a promise to never give up. As I said before, there is information that can prove that Mom's life was lost to a lack of care. It is clearly indicated in documentation that is easily accessible to anyone in law enforcement. Anyone with a family member in the supposed care of  a SanStone operated facility, they will lie cheat and steal whatever they can. Maybe through the lack of care they are getting paid for or simply charging for medication that is unnecessarily prescribed, or not even administered. All of this can be verified by simple review of records and a little investigating.
More to come, next post: the NC Board of Nursing , and the NC Medical Board 

The Quest continues, Chapter two - The FBI

After being told by the NCDHSR that there was no where else we could go, we kept trying anyway. My brother had read an article about the H.E.A.T. task force , a combination of FBI and agents from the Inspector General (OIG). I attempted to contact the FBI from one angle, and my brother from another. My brother was successful at setting up a meeting at the Asheville NC office of the FBI.
The agent we met with was not even aware of the H.E.A.T. taskforce, but was willing to hear our story.
An agent met us in the lobby of the Federal Building in Asheville and escorted us to the waiting area of the FBI office. After several minutes, another agent led us into a small windowless office with his desk and two chairs. There were two cameras in the corners opposite where we sat, and two doors, one to the lobby, and one to another area in the back.
The conversation began with the agent stating that very few people ever get past the lobby, and that our accusations were very serious. My brother had spoken to him on the phone and given him the short story. We proceeded to present the evidence we had collected, medical records, sworn witness statements and other documents we had acquired. At the time of our initial meeting, I had not yet received the copy of the NCDHSR report of their investigation that had been requested through the FOIA ( freedom of information act ). These records were held up by the CMS for over one year, they would have been seriously incriminating at the time.
There were letters from Alfreda Walker of the CMS ( centers for medicare and Medicaid services ) in response to my contact with Congressman Heath Shuler. There was a signed sworn account of Mom's fall from her roommate. My brothers wife presented a spreadsheet of inconsistencies in the medical records and other information we had collected. Letters from the NC Medical Board and the NC Board of Nursing.
The combination of documents presented indicated plenty of indications that there were laws being broken. There was evidence of Medicare fraud, stolen drugs, fraudulent medical records, perjury, kickbacks, racketeering and manslaughter. The meeting lasted for two hours and was very intense.
The agent was extremely certain that there was more than enough to begin an investigation. He indicated that we should avoid contacting Dr. Russell, Hendersonville Health and Rehabilitation, and the NCDHSR or Gail Maloney!
When we left the FBI office, it seemed like we could finally rest and let the authorities do their job. I remember my brother and I hugging outside the Federal Building in tears.
The agent kept in touch for a year or so, and we met one other time with the initial agent and another agent, Andy Romanello. Agent Romanello treated us in an adversarial fashion, he was also unaware of a Federal law that we alleged was being violated. Although we presented him with documentation, he refused to look at the file. The meeting lasted over an hour and agent Romanello never even looked at the evidence we presented.
The initial agent has been transferred to another division of the DOJ and we have never heard from agent Romanello. That is where things were left with the FBI. It is entirely possible that they are still investigating our allegations. Believe me there is plenty of information to indicate that there are still laws being broken. The problem is that the Federal authorities don't seem to have the time or the staff to thoroughly investigate. If you consider the amount of money taken in by the nursing home industry, it would be hard to get around their influence. There is certainly no chance that a private citizen has a chance.
Mom died in November of 2011, and we have been after truth and justice since then. After all we have been through we have not given up. There is still contact with a Congressman, CMS and the OIG.
More to come, next chapter will be the OIG  , (Office of the Inspector General )

The quest for truth and justice ! The NCDHSR chapter.

In four and a half years, I have been fighting for justice. I am certain that Hendersonville Health and Rehabilitation , and Dr. Larry Joe Russell were responsible for Mom's death. I believe that if she were properly examined after her fall, she would still be alive. Trust me this is not just me looking for someone to blame. I believe there is undisputable proof in the records from Hendersonville Health and Rehabilitation and subsequent DHSR investigation. The problem is that no matter what I've done, I cant get anyone to even look.
The first step we took, was to file a complaint with the NCDHSR against Hendersonville Health and Rehabilitation. My brother and I filed separate complaints alleging different violations. The reply to both complaints from the NCDHSR was " no deficiencies found ". This prompted us to request a meeting with Gail Maloney, the Western Regional Director of the NCDHSR at the time. Four family members met with Ms. Maloney at the office in Black Mountain. Ms. Maloney's' attitude was confrontational from the beginning.
At the meeting, we reviewed the list of items from Mom's medical records that were inaccurate. The most obvious being the wrong room number and bed on almost every page, including the medication administration record. Some of the things we discussed were, missing medications, altered nurses notes, missing information, conflicting notes on what happened the morning she died and more. Mom's roommate the night she fell, gave a whole different account of the fall than was reflected in the nurses notes. The nurses account of the fall was marked " late entry" and was dated December 1, one month after Mom passed.
Our meeting lasted almost two hours and Ms. Maloney was defending the actions of Hendersonville Health and Rehabilitation the entire time. When asked what happened to the missing Ativan, Ms. Maloney replied " they must have put it back ".Even though according to the records they were prescribed and the prescription was filled by Blue Ridge Pharmacy , the pharmacy provider for Hendersonville Health and Rehabilitation. The NCDHSR guidelines state that medications be disposed of, and there has to be two people present to witness the disposal. You might think that Ms. Maloney as the regional director of NCDHSR would be familiar with their own regulations. The meeting was extremely disappointing, and there was no indication that our concerns were ever going to be addressed. At the end we asked where else we could take our concerns and Ms. Maloney simply stated that she was the end of the line, there was nowhere else we could go.
Ms. Maloney told us they would review the records and our information, and we would hear from them in the future. It took quite some time before we heard anything from the NCDHSR, and when we did they reaffirmed that there were no deficiencies as reported in the original investigation. Ms. Maloney is no longer the director, she was replaced by Todd Davis, who just happened to be the lead investigator of our complaint!
We were told that we could request a copy of the investigation through the FOIA ( freedom of information act ). I filed the required forms with the FOIA and requested the records. It took almost two years, several phone calls and emails before I actually received the report. Some of the investigation records were redacted and some of the names were blacked out. Still there was plenty of information that indicated the investigation was not taken seriously. The report reads almost like it was written by the staff at Hendersonville Health and Rehabilitation. Even the results of the
" review" were suspicious. There were two different letters written by the Doctor that did the review, and neither one had the correct chain of events, dates and facts.
That was just the beginning of my frustration with the system and trying to get them to do their job.  More to come later on the quest for truth and justice!

Do right and wrong exist in the nursing home industry, is there such a thing as justice ????

All my life I was taught that there was right and there was wrong. What I can tell you now that the difference between the two boils down to how much money you have, and who you buy with that money. I would bet that the NCDHHS can be bought for simple favors and special donations.  Since the morning of November 11, 2012 when my Mother died, I have been fighting the money that did the wrong.
First the wrong in how nursing homes are raking in profits, while neglecting the care of their patients. All you have to do is walk into almost any nursing home in the evening or on weekends and you will notice the lack of staff on duty. The majority of nurses hours are worked in the daytime hours through the week. They know that the majority of visitors and any inspectors from DHHS will come in the day during the week. At night there may be one actual nurse on duty and the rest of the staff are CNA's.

During moms stay in Hendersonville Health and Rehabilitation, we had to practically beg to get her a shower. Even when we were promised that she would get a shower on more than one occasion it never happened. According to her records, Mom was supposed to get help with her meals because she couldn't see very well. The only help she ever got with meals was from family members. We made a point to assure that one of us was there for as many meals as we could. If we were not there at mealtime, the food was simply wheeled into the room and sat on the tray. If Mom was able to eat what she was served, there would be food on her clothes and in her bed.

Second, the wrong in the NCDHHS who is supposed to inspect and investigate complaints against nursing homes. These so called inspectors are either very stupid or they are being paid off by the wealthy nursing home owners. I have copies of Mom's records from Hendersonville Health and Rehabilitation and copies of the inspection report. The inspection overlooks things like missing medication, a non reported fall, wrong room number on most of the records, fraudulent nurses reports, conflicting statements by Dr. Russell, and a sworn notarized statement by Mom's roommate.

The wrongs just keep on coming. The fact that the NC State Medical Examiners office declined a required autopsy, due to a fraudulent document from Hendersonville Health and Rehabilitation. The fact that the NC Board of Nursing ignored the wrongs done by Lara Mooney LPN and Susan Habel, RN when they fraudulently created her nurses note one month after Mom's death. The wrongs in the "MAR", Medication Administration Records showing Ativan then not showing Ativan.

Dr. Russell stating that he saw Mom on the morning of her fall, as he was on premises that morning. Then later stating that he did not see Mom the morning of the fall. Going on to say that in his medical opinion, he agreed with the nurses assessment and that they had made the right decision for no further treatment. Mom was dead two days later, from no apparent cause.

The wrongs just keep adding up, all because of the false records and statements made by Hendersonville Health and Rehabilitation . The failure of the NC Pharmacy Board, to look at the disappearing medication and the sloppy records. The wrong in the connections between Dr. Russell and Blue Ridge Pharmacy, DR. Boleman and Pardee Hospital and the fact that Hendersonville Health and Rehabilitation was built and owned by Pardee Hospital.

I have repeatedly accused specific people of doing specific things that violate the law and their professional oaths. It is interesting that not one of these people has accused me of making any of this up!
There is plenty more to come, just too much for one sitting. Feel free to read past posts for more insight. Also please comment if you wish, people need to hear your stories as well.