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Dan Shively had been a financial institution president who constructed floats for July Fourth parades in Cody, Wyoming, and adored fly-fishing along with his sons. Jeffrey Dowd had been an auto mechanic who ran a canine rescue and hosted a Sunday blues radio present in Santa Fe.
By the point their lives intersected at Canyon Creek Reminiscence Care Group in Billings, Montana, each have been deep within the grips of dementia and exhibiting a few of the illness’s horrible traits.
Shively had been wandering misplaced in his neighborhood, having outbursts at house, and leaving the gasoline range on. Dowd beforehand had been hospitalized for being confused, suicidal, and agitated, medical information filed in U.S. District Court docket in Billings present. When Dowd entered Canyon Creek, managers warned staff in a be aware later filed in courtroom that he might be “bodily/verbally abusive when pissed off.”
On Shively’s fourth day at Canyon Creek, carrying a knife and fork, he walked over to a eating room desk the place Dowd was sitting. Dowd instructed Shively to maintain the knife away from his espresso, in keeping with a witness assertion filed in courtroom. Shively, who at 5-foot-2 and 125 kilos was half Dowd’s weight and 10 inches shorter, turned to stroll away, however Dowd stood up and shoved Shively so exhausting that when he hit the ground, his cranium fractured and mind hemorrhaged, in keeping with a lawsuit his household filed towards Canyon Creek.
“The physician stated there’s not a lot they may do about it,” his son Casey Shively stated in an interview.
Dan Shively died 5 days later at age 73.
Police didn’t cost Dowd, then 66. He stayed at Canyon Creek for almost three extra years, throughout which period he repeatedly clashed with residents, typically hitting male residents and groping feminine ones, in keeping with facility information filed within the courtroom case. His anger would flare rapidly. “I’m actually scared to loss of life of Jeff,” one nurse wrote in a filed assertion describing Dowd’s dispute with one other resident.
In courtroom, Canyon Creek denied legal responsibility for Shively’s loss of life. Its privately held company proprietor, Koelsch Communities, declined to reply questions from KFF Well being Information. Chase Salyers, Koelsch’s director of promoting, stated in an e-mail to KFF Well being Information that the corporate prioritizes “the well being, well-being, security, and safety of our residents.”
Dowd’s relations stated in a press release through textual content they’d not remark as a result of they’d no firsthand data. “We have been more than happy with the care Jeffrey obtained at Canyon Creek,” they added. Dowd was not named within the lawsuit and his present whereabouts couldn’t be decided.
Violent altercations between residents in long-term care services are alarmingly frequent. Throughout the nation, residents in nursing properties or assisted dwelling facilities have been killed by different residents who weaponized a bedrail, shoved pillow stuffing into an individual’s mouth, or removed an oxygen mask.
A recent study in JAMA Community Open of 14 New York assisted dwelling properties discovered that, inside one month, 15% of residents skilled verbal, bodily, or sexual resident-on-resident aggression. One other examine discovered almost 8% of assisted living residents engaged in bodily aggression or abuse towards residents or employees members inside one month. Dementia residents are especially likely to be concerned in altercations as a result of the disease damages the components of the mind affecting reminiscence, language, reasoning, and social habits.
Greater than 900,000 people with Alzheimer’s or different varieties of dementia reside in nursing properties and assisted dwelling facilities. Lots of the most significantly impaired stay within the roughly 5,000 services with locked dementia flooring or wings or the three,300 properties devoted completely to reminiscence care. These locations are principally for-profit and infrequently cost 1000’s of {dollars} additional a month, promising experience within the illness and a protected setting.
Clashes may be spontaneous and too unpredictable to forestall. However the likelihood of an altercation will increase when reminiscence care properties admit and retain residents they will’t handle, in keeping with a KFF Well being Information examination of inspection and courtroom information and interviews with researchers. Houses which have too few staffers or nonexistent or perfunctory coaching for workers have a tougher time heading off resident conflicts. Houses additionally might fail to correctly assess incoming residents or might hold them regardless of demonstrated threats to others.
“As a lot as long-term care suppliers generally do their greatest to offer competent, high-quality care, there’s a actual downside with endemic violence,” stated Karl Pillemer, a gerontologist at Cornell College and lead creator of the JAMA examine.
“There must be rather more of an effort to single out verbal and bodily aggression that happens in long-term care,” he stated, “and start to create a mannequin of violence-free zones in the identical approach we’ve got violence-free zones within the faculties.”
The primary indicators of Shively’s vascular dementia emerged in 2011 as confusion, however the illness accelerated in 2016, in keeping with interviews along with his spouse and youngsters and his medical information. He started referring to mountains he knew properly by the fallacious identify and forgot find out how to tie flies on his fishing line. “The decline was so sluggish at first we thought we may handle,” his spouse, Tana Shively, stated in an interview earlier than her death this yr.
Because the illness progressed, his outbursts grew to become exhausting to deal with. He took a swing at one in every of his sons when upset concerning the temperature in the home. He refused to swallow his drugs and fell repeatedly.
“He would begin strolling the neighborhood and get misplaced,” Casey stated. “He would activate the gasoline range however not mild the range, and the room would begin filling up with gasoline. He would put clothes in unusual locations. I discovered socks in a punch bowl. It obtained to the purpose the place we couldn’t do that anymore.”
Dowd, in the meantime, had lived in a Santa Fe nursing house and had a protracted historical past of dementia with behavioral points, main depressive dysfunction with psychotic options, and hypertension, in keeping with medical information filed in courtroom. Dowd entered Canyon Creek in October 2018 to be nearer to his brother, who lived close by in Wyoming, in keeping with an admission discover the ability supplied to staff that was included within the courtroom document. The discover stated Dowd suffered from dementia caused by excessive and long-term alcohol use.
Two months later, Shively moved in.
Montana licenses Canyon Creek, which has 67 beds, as a Stage C assisted dwelling facility, which allows it to deal with individuals with cognitive impairments so extreme that they can’t specific their wants or make fundamental care selections. Montana law says these services can not admit or retain a resident who’s “a hazard to self or others.”
Within the lawsuit, Shively’s household argued that, provided that legislation, Canyon Creek by no means ought to have accepted or stored Dowd. The Shively household’s lawyer, Torger Oaas, famous in courtroom papers that Canyon Creek’s consumption evaluation kind for Dowd categorized his habits as “bodily and/or verbally abusive/aggressive 1x per thirty days.” Oaas additionally wrote in courtroom papers that in Dowd’s first weeks at Canyon Creek, he mocked and threatened to hit different residents and threw somebody’s silverware to the bottom throughout dinner.
In its protection filings within the lawsuit, Canyon Creek stated the Montana statute was too broad to be the idea of a negligence declare and argued that every one reminiscence care residents are unpredictable. And whereas Dowd had yelled and cursed at different residents at Canyon Creek, he hadn’t had bodily confrontations — or any conflicts with Shively, Canyon Creek stated. “The accident was not fairly foreseeable,” Canyon Creek argued.
Within the days after Shively’s fall, nurses famous that Dowd was “extra anxious, indignant towards others.” Dowd yelled at a nurse to get off the cellphone and “do your job,” a nurse wrote in a logbook entry filed in courtroom.
“He obtained into my face,” the nurse wrote. “It seemed like he was going to hit me — he had his hand/fist raised.”
Folks with dementia will lash out as a result of they now not have social inhibitions or as a result of it’s the one approach they will specific ache, discomfort, worry, disagreement, or nervousness. Some common triggers — overstimulation from loud noises, a frenzied environment, unfamiliar faces — are hallmarks of dementia care establishments.
“We are able to’t count on somebody who is continually and unfailingly disoriented to adapt to the environment anymore,” stated Tracy Wharton, a licensed scientific social employee and dementia researcher in Florida. “We have now to adapt to them.”
Eilon Caspi, a University of Connecticut researcher, analyzed 105 deadly incidents involving dementia residents and located 44% have been deadly falls through which one resident pushed one other. “Some individuals are aggressive, and a few are violent,” Caspi stated, “however in the event you look carefully, the overwhelming majority are doing their greatest whereas dwelling with a severe mind illness.”
Holly Harmon, a senior vp on the American Well being Care Affiliation/Nationwide Heart for Assisted Dwelling, an business commerce group, stated in a written assertion that conflicts can not at all times be averted regardless of facility operators’ greatest efforts. “In the event that they do happen,” she stated, “suppliers reply promptly with interventions to guard the residents and employees and stop future occurrences.”
However Richard Mollot, govt director of the Lengthy Time period Care Group Coalition, a resident advocacy group, stated many operators of assisted dwelling facilities, together with reminiscence care items, are pushed by the underside line. “The difficulty that we see very often is that assisted dwelling retains individuals they need to not,” Mollot stated. “They don’t have the staffing or the competency or the construction to offer protected care.” Conversely, he stated, when services have sufficient rooms full of paying clients, they’re extra more likely to evict residents who require an excessive amount of consideration.
“They’ll kick them out in the event that they’re too cumbersome,” Mollot stated.
Teepa Snow, an occupational therapist who based Positive Approach to Care, an organization that trains dementia caregivers, famous that the house inside many services, with double rooms, tight frequent areas, and restricted outside entry, can gasoline conflicts. She stated the pandemic degraded situations in long-term care, as dementia residents with restricted social expertise atrophied in isolation of their rooms and staffing grew even sparser.
“It’s as unhealthy as I’ve ever seen it,” she stated.
The next account of Dowd’s time at Canyon Creek relies on 44 pages of nurse’s notes, witness statements, and inner resident-on-resident altercation experiences; all have been contained within the facility’s information and filed as displays within the courtroom case. After Shively’s loss of life in December 2018, Dowd was given new prescriptions, though the courtroom document is unclear if the change was due to Shively’s loss of life. Nonetheless, the information present, Canyon Creek was unable to go off recurring altercations involving Dowd.
Some have been verbal threats. As soon as, Dowd yelled at residents in the lounge to close up, referred to as them “retards” and instructed them they need to all die, a caregiver wrote in a witness assertion. He grabbed one resident’s face and threatened to kill him, in keeping with a nurse’s be aware. One other time, Dowd went as much as a resident sitting on a settee and grabbed his walker. Dowd shook it and instructed him to close up. In response to a witness assertion, as a nurse took the resident to the lavatory, Dowd muttered below his breath: “Stuff his head in the bathroom.”
Different conflicts have been bodily. Dowd shoved a resident “down on his again so exhausting his head bounced off the ground,” a nurse recorded in a be aware. In a special incident reported by a nurse, Dowd pushed a resident who had been agitated and cursing right into a chair. On separate events, Dowd hit two residents on the pinnacle, as soon as inflicting bleeding, in keeping with two resident altercation experiences.
The notes element that Dowd was not at all times the initiator. As soon as, Dowd’s roommate scratched and punched him after Dowd instructed him to make use of the bathroom fairly than pee on the ground, leading to a combat. Caregivers separated the 2. One other day, a resident named Invoice wandered into Dowd’s room and pulled Dowd’s hair and beard. Dowd instructed the nurses he “felt unsafe and VERY indignant,” a nurse’s be aware stated. The nurse led Invoice out of Dowd’s room, however Dowd adopted, yelling at Invoice that he was “a fats bastard” and saying he was going to make Invoice’s spouse a widow.
“Jeff stored making a closed fist as tho he was going to hit Invoice,” the nurse wrote in a witness assertion. “I used to be legit scared as a result of there was nothing I may do to defuse the scenario. I’m actually scared to loss of life of Jeff. I’m scared to strategy him and discuss to him when he will get into these quite common suits of rage.”
Dowd finally went again to his room and a employee locked his door so no different resident would go in.
The information describe how Canyon Creek caregivers intervened after altercations started, usually separating the preventing residents and updating Dowd’s brother on the clashes. Nurses would take away Dowd or the opposite resident from a room and discourage such acts. “Tried to elucidate it was inappropriate to harm others,” one nurse wrote after one incident.
Salyers, the corporate advertising director, stated in his e-mail that the employees at Canyon Creek and different Koelsch services are “extremely certified” and “extensively educated.” He stated the corporate’s reminiscence care communities are “distinctively designed and staffed” for individuals with Alzheimer’s and different types of dementia.
The nursing notes and statements within the courtroom file recommend that incidents have been frequent sufficient that nurses commented on Dowd’s occasional serenity. “No agitated or aggressive behaviors this shift,” one be aware stated. One other nurse be aware stated Dowd “continues to isolate at meals, sitting at a desk by himself.” Whereas Dowd loved studying books and doing puzzles, he was overheard saying he was depressed and was “questioning if he wouldn’t be higher off if he wasn’t round anymore.”
Nurses famous Dowd repeatedly exhibited sexual habits that was both inappropriate — making “crude oral gestures whereas taking a look at youthful females” — or ambiguous, akin to inserting his hand on a resident’s shoulder and commenting, “It’s good to have a girlfriend.” Somebody noticed Dowd “grabbing on a number of residents[’] personal areas,” a witness assertion stated. When nurses caught the habits, they separated these concerned and rebuked Dowd. A employees member wrote in a press release that Dowd was inappropriate all through her shift, making sexual jokes and “making an attempt to seize me.”
In response to nursing notes, in summer time 2021, Dowd instructed one feminine resident he needed to see her genitals and later touched her breast. In August, a caregiver walked into Dowd’s room and located him touching the identical resident below her shirt and pants. The caregiver instructed Dowd to “cease it and never ever try this once more” and introduced the lady out to fulfill her household, who had come to go to her.
After that incident, Canyon Creek despatched Dowd to the emergency room at Montana State Hospital, a public psychiatric facility, in keeping with a nurse administrator’s testimony in a deposition filed in courtroom. The nurse testified Dowd was now not at Canyon Creek. That’s the final point out of Dowd’s whereabouts within the public document. A spokesperson for the Montana Division of Public Well being and Human Companies, which oversees the hospital, wouldn’t affirm whether or not he was a affected person.
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At a pretrial listening to, the decide excluded dialogue about Dowd’s altercations after Shively’s loss of life. In a courtroom submitting, Shively’s lawyer requested permission to share proof with the jury that Canyon Creek gave its govt director a bonus any month when 90% or extra of the beds have been stuffed so he may argue Canyon Creek had a monetary motivation to confess Dowd. However the decide additionally barred that data from the trial, which Canyon Creek stated in a courtroom submitting was irrelevant.
The Shively case went to trial in 2022 earlier than a federal civil jury in Billings. Regardless of the exclusions, the jury determined Canyon Creek’s negligence induced Shively’s loss of life. It awarded the household $310,000.
“For us, the cash wasn’t an enormous issue,” stated Spencer Shively, one other of Dan Shively’s sons, who referred to as the damages so modest as to be a victory for Canyon Creek or its insurer. “At the least they have been negligent per se. However I don’t understand it actually modified something. For me, I obtained some closure. I really feel like these services are simply persevering with to do the identical issues they’re going to do as a result of there hasn’t been systemic change.”
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