By Diana Washington Valdez
The El Paso Times
EL PASO, Texas — Missteps by the El Paso State Supported Living Center may have contributed to the death of a resident two years ago, according to state government documents.
Oxygen therapy for the late 47-year-old John Conner was not administered correctly, and he should have been sent to a hospital by ambulance sooner, the documents show.
Lois Conner, John Conner’s mother, said she never received any of the documents that explained how her son died in a matter of days.
“He died at Providence Hospital from pneumonia,” said Lois Conner, of El Paso. “I requested an autopsy because although my son did become ill at times, I wanted to know what happened. We were told then that they couldn’t find someone who was willing to do the autopsy.
“I never received a report of any kind, and although I requested the autopsy, I never got to see an autopsy report with the results,” Conner said. “I was told by telephone that the autopsy showed that John had died of pneumonia, but I can’t recall who it was that called.”
State Center Director Jaime Monardes did not return phone messages seeking comment. An assistant at the center referred questions to the Texas Department of Aging and Disability Services (DADS), which oversees the 145-bed center that helps people with special needs.
Cecilia Cavuto, spokeswoman for DADS, said in a statement that “without a signed release from family or a legally authorized representative, privacy laws prevent us from discussing the people we serve, particularly confidential medical information, even after they have passed away.”
“It is important to note that all deaths are thoroughly reviewed, and since September 1, 2010, we have put in place an additional independent process to review every resident death.”
The center in El Paso is one of several state centers in Texas that the U.S. Department of Justice is monitoring for previous complaints of alleged abuse and neglect.
Earlier this year, a Justice Department monitoring report found that the El Paso State Supported Living Center was found to comply with 32 of 171 health and safety requirements.
The center is supposed to provide 24-hour residential services, including comprehensive behavioral-treatment services and health-care services, including physician, nursing and dental services.
Lois Conner said she visited her son regularly at the center and would show up at different times of the day and on different days so the staff would not expect her at any one time. Before he was transferred to the El Paso State Center, John Conner was a resident at a similar facility in Abilene.
‘Like 6-month-old baby’
“I had John at home until he was 6 years old. He was like a 6-month-old baby,” Conner said. “He was hydrocephalic (abnormal volume of fluid in the brain), and he was diagnosed with Down syndrome when he was 25 years old. We were glad when he was admitted to the El Paso center, so we could visit him more often.”
John Conner could not speak or move much on his own, but he could roll over and lift his hands and reach for things.
“He was aware of you, and his eyes would follow you whenever you moved or spoke,” his mother said. “He watched movies on his TV and listened to music.”
Conner said she bought him two recliners so he could sit comfortably in the center’s recreation room and in his bedroom.
“I went to see John a couple of days before his death at the center when I noticed that his breathing was labored,” Conner said. “He had a feeding tube, which in his case had been a good thing because he was fed and given his medications without trouble. I mentioned my concerns at the time to the nurse at the center.”
On Jan. 1, 2010, nurses had reported that John Conner was “alert and awake,” and showed no signs of distress or discomfort.
Three days later, the center doctor’s plan for John Conner was to “continue with current care plan and programming. He (the doctor) had an initial discussion whether to send him to the emergency room, but the individual (Conner) had clear breath sounds, good skin color, normal heart rate, no (fever),” state documents state.
The documents said no medication was prescribed, and he was to return to the State Center clinic in four days.
Also on Jan. 4, the center’s doctor determined that John Conner exhibited lethargy, but that he “was probably sleeping soundly,” the documents state. Two days later, on Jan. 6, 2010, Conner started to display “shallow mouth breathing,” and decreased oxygen saturation, according to the documents.
The licensed vocational nurse on duty tried to call the on-call supervising nurse but was unable to reach her. The vocational nurse then called the systems nurse manager, who recommended increasing the oxygen for Conner, the documents state.
There was no record of any actions the two nurses at the center took between 1 and 2 a.m. on Jan. 6, 2010. At 3 a.m., a vocational nurse contacted a doctor because Conner’s oxygen saturation level was falling, and he was lethargic and unresponsive to stimuli. Finally, an ambulance was called, the documents state.
Lois Conner said someone called her on Jan. 6, 2010, to tell her that her son had been hospitalized. She rushed to see him, and he died later that day. Serious failures
According to a government report, several serious failures occurred before Conner died. One of the failures noted was the fact that the center had hired a vocational nurse who was not licensed to practice in Texas. The center fired the nurse after Conner’s death, according to the report.
The report also noted these deficiencies:
Failure to develop a proper on-call duty procedure.Failure to develop a supplemental oxygen therapy policy and protocol for the nursing staff.Failure to follow procedures for all registered and vocational nurses about when to send a resident to a hospital emergency room.Failure to seek clarification or instructions for revised oxygen therapy from a doctor.Failure to follow standards of nursing practice.Failure to assess a resident’s health status for an entire hour (1 to 2 a.m) on Jan. 6, 2010, including vital signs, oxygen saturation and responsiveness.Failure to recognize signs and symptoms of seriously decreased oxygen levels, and failure to take timely and appropriate nursing intervention, to include notifying the doctor when the oxygen level dropped below 90 percent.
Conner’s oxygen level had dropped to 30 percent, while 90 percent is normal.
“Both LVNs and System Nurse Manager failed to respond to the resident’s serious hypoxia (inadequate oxygen level) in a timely manner,” according to the report.
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