Thousands of America's elderly mothers, fathers and grandparents are being killed each year in the nation's nursing homes - frail victims of premature and preventable deaths.  This quiet pandemic is rarely detected by government inspectors, investigated by law enforcement, appraised by medical examiners or prosecuted by anyone.  These deaths are not at the hands of crazed "angels of death."  Most are caused by fatal neglect traced to caregivers upon whom residents depend for food and liquid and for turning them in their beds to prevent the formation of life-threatening sores, say investigators and leading researchers in elderly care. "Unlawful abuse and neglect is widespread, underreported, infrequently prosecuted and the cause of untold suffering, injury, illness and death," Marie-Therese Connolly, who heads the U.S. Department of Justice Nursing Home Initiative, says in a study published last month in the Journal of Health Care Law and Policy.  These are examples of the types of deaths Connolly describes:

Pulaski County, Arkansas coroner Mark Malcolm (left) and deputy coroner Tim Irizarry remove the body of Willie B. Harris, an 83-year-old woman, for autopsy after she died in a North Little Rock nursing home. Malcolm decided to further investigate the death after talking to family members who detailed past treatment for broken ribs and recurring infections.

Ruby Faye Martin, 88, died in Mount Vernon Countryside Manor in Mount Vernon, Ill., of sepsis, an overwhelming bacterial infection that poisons the blood. An evaluation of her medical records by a doctor who specializes in medical problems of the elderly stated that the death was caused or exacerbated by malnutrition and multiple infected bedsores caused by poor care at the nursing home. A home official declined to comment.

Rex Riggs was in stable condition when transferred to Beverly Healthcare nursing home in Neosho, Mo., according to Veterans Administration doctors. Six weeks later, the disabled Vietnam War veteran, 57, was hospitalized with gangrenous infections that led to the surgical removal of his scrotum, penis and lower abdomen. He died three days later. Federal investigators said bad nursing care caused his death.

Prosecutors charged no one in the three cases.

Government documents and court records reviewed by the Post-Dispatch show hundreds of similar deaths caused by neglect in nursing homes across the nation. 

The latest national compilation of more than 500,000 nursing home deaths - for 1999 - lists starvation, dehydration or bedsores as the cause on 4,138 death certificates. The data, collected by the National Center on Health Statistics, include 138 such deaths in Missouri and 186 in Illinois. 

But death certificates alone don't begin to tell the story. 

A handful of investigators and researchers, working in specific geographic areas, took the time to compare patient medical records with their death certificates. Plaintiffs' lawyers, representing aggrieved relatives across the country, have gone through the same exercise.

Their findings indicate that the number of preventable deaths attributable to malnutrition, dehydration and bedsores from bad care or no care is much higher. 

Louisiana Sen. John Breaux, a Democrat and chairman of the Senate Special Committee on Aging, called deaths from nursing home neglect "a hidden problem." 

"We know it's significant," said Breaux, noting that investigations by his staff and other research show that 500,000 to 5 million cases of elderly neglect and abuse take place in institutions and private homes each year, although about 80 percent go unreported. 

"The number of avoidable deaths of our elderly could be in the tens of thousands," said Breaux, who along with Republican Sen. Orrin Hatch of Utah last month introduced the Elder Justice Act, which seeks to prevent such deaths. 

Many medical and regulatory investigators who work in nursing homes every day characterize the number of wrongful deaths in terms such as "massive" and "pervasive," based on their daily experience. Most of the deaths can be traced to an inadequate number of nurses and aides to provide life-sustaining care. The U.S. Department of Health and Human Services reported to Congress this year that nine out of 10 nursing homes have staffing levels too low to provide adequate care.

There are a number of reasons for the shortages, which plague the entire health care industry, including hospitals. Many workers are unwilling to accept poverty-level wages for unpleasant, demanding work that often requires mandatory overtime or double shifts. Constant corporate focus on the bottom line frequently requires managers to operate homes with skeleton staffing because the industry says it lacks enough government money to provide proper care. 

Yet, some nursing homes find ways to provide adequate service with existing staff. Many nurses and aides are dedicated to their profession and provide excellent, compassionate care. 

The American Health Care Association, the lobbying group for most of the nation's nursing homes, says malnutrition, dehydration and bedsores "are common conditions associated with the frail elderly, especially at the end of life." 

"AHCA states unequivocally that any incident of neglect or abuse is unacceptable, but drawing a link of patients passing away from these maladies as a result of alleged poor care is simply irresponsible," the trade group said in a statement. 

Finding deaths by neglect 

Government studies in two states and the work of plaintiffs' legal teams begin to document the magnitude of the problem. 

In 1998, the General Accounting Office assigned three registered nurses (two with advanced degrees in gerontological nursing) and a physician to determine what had actually killed 62 people who had died in California nursing homes. They were randomly selected from nursing homes that had multiple deaths, the GAO said. 

The GAO, which is Congress' investigative arm, subpoenaed medical records and nursing notes, some of them 600 pages long. Its investigation determined that 34 of the 62 had received "unacceptable care" and had died of dehydration, malnutrition or raging infections from uncontrolled bedsores. 

For example, one man lost 59 pounds - one-third of his weight - over seven weeks. A woman who had weighed 100 pounds dropped to 54 pounds before her death, and another woman developed four pressure sores so severe that they ate through to her bones. She received pain medication only three times during five weeks of painful daily treatments for the infections, the GAO investigator reported. 

A year later, in 1999, complaints from nursing home workers, family members and Arkansas long-term care inspectors who believed that poor nursing care was killing residents troubled Little Rock Coroner Mark Malcolm.

"I didn't know. Nobody knew," Malcolm said. "These poor souls were cremated or buried with no one but the nursing home or its doctor deciding why they died - whether it was natural causes or because they weren't properly cared for." 

Malcolm and his deputies reviewed about 100 questionable nursing home deaths that occurred from 1993 to 1999. They interviewed families and nurses and examined whatever clinical information was available on the deceased, including medical records and nursing home charts. Seven bodies were exhumed. 

Working with the medical examiner's office, Malcolm determined that more than 30 percent of the death certificates listed an incorrect cause of death. 

"The families were being told by the nursing homes that their loved ones died of heart attacks, strokes and other natural causes, but what we actually found was that about a third were wrongful and preventable deaths, either caused by or exacerbated by dehydration, malnutrition, including choking, or from sepsis from bedsores," said Malcolm, who was just appointed to the U.S. Department of Justice's newly formed forensic working group. 

Although the number of cases reviewed was not enormous, the finding was significant enough to get the Arkansas Legislature to immediately pass a law - the only one in the nation - that demands that nursing homes notify a coroner of every death. 

Arkansas nursing home regulators say the new law already has had a strong deterrent effect. The number of citations for life-threatening care issued against the state's nursing homes dropped after the law took effect. 

Lawyers examine deaths 

In every state, there is a group of professionals who routinely compare the cause of death listed on death certificates with the medical records of deceased nursing home residents. They are lawyers representing families who believe their loved ones were killed by poor care or no care. 

An examination by the Post-Dispatch of hundreds of these court cases across the nation found that the vast majority of death certificates attributed the deaths to natural causes such as pneumonia, heart attack and - in some cases - "cessation of breathing," "heart stopped," "old age" or "body just quit." 

"Our staff examines hundreds of alleged wrongful nursing home deaths a year, and only a handful of the death certificates reflected what medical records showed actually killed the person," said Tim Dollar, whose law firm in Kansas City is Missouri's largest litigator of nursing home deaths. "Some physicians go to amazing lengths to avoid admitting that by omission or commission, the nursing home killed these people."

The Post-Dispatch examined the death certificates and the physicians' evaluations of 55 nursing home residents in Missouri and Illinois who died in the past two years and whose relatives decided to sue for neglect. In 42 of the cases, the newspaper found that the cause of death listed on the certificate differed from what physicians said the medical records actually showed. In 40 of these cases, the nursing homes involved agreed to a settlement with the family before trial or were found in civil proceedings to have committed neglect.

A deadly trio of neglect 

The three causes of death that the Post-Dispatch examined in its yearlong investigation - malnutrition, dehydration and bedsores - were selected because government investigators and medical experts said an overwhelming majority of such cases are preventable with proper nursing care.

When left untreated, any of the trio spawns a domino effect of system failures that can kill. 

"It's like a house of cards. One slips out and the whole thing comes crashing down, and death is often inevitable," said Dr. Margaret Wilson, a gerontologist and researcher at St. Louis University. Specifically: 

Malnutrition can reduce immunity from infections to an almost AIDS-like state and can quickly cause loss of muscle strength, which can lead to increased frailty, pneumonia, kidney and liver failure, and death. 

Dehydration can lead to dangerously low blood pressure, which can generate strokes and heart attacks. It also can cause infections, kidney failure, uremic poisoning and death. 

Decubitus ulcers or bedsores can result in flesh being eaten away down to bone and organs, causing a life-threatening toxic poisoning called sepsis. The sores come from the weight of the person's body pressing on a bone while lying in bed, which compresses the blood vessels in the skin and underlying tissues. Within only two or three hours, red, burnlike wounds appear. If left untreated, this tissue then begins to decay from lack of blood circulation. 

The industry trade group said that many pressure ulcers develop before a resident enters the nursing home - a statistic it says is not often reported. 

Medical authorities estimate that 12 percent to 15 percent of the deaths from the three causes could not have been prevented. They cite residents who have decided not to eat or drink. Others have diseases that aggravate bedsores or that impede the consumption of nutrition. Still others have living wills or advance directives that preclude supplemental food, liquid or medical treatment. Even allowing for those exceptions, the number of preventable nursing home deaths is far greater than reported. 

"It isn't rocket science to say that you need enough staff to help every resident with eating, drinking and infections. It's not like we need to discover the cure for the Nile virus," said Catherine Hawes, a professor and director of Texas A&M University's Southwest Rural Health Research Center and a national authority in evaluating nursing home quality. "We know how this is supposed to be done, but in all too many places it's not." 

An earlier tragedy 

This isn't the first time that government regulators, law enforcement and medical professionals failed to detect that vulnerable victims were being killed. 

"These preventable deaths in nursing homes are almost parallel to the realization 30 years ago that child abuse was an undetected and lethal problem," said Paul Weidenfeld, an assistant U.S. attorney in New Orleans. 

Children would be rushed into emergency rooms with concussions or broken necks. Doctors would call the deaths tragic and chalk it up to the fact that babies fall out of cribs and kids tumble from trees or down stairs. 

"Finally, people started questioning: How did the child fall? Why did that happen? And it was realized that enormous numbers of children were being abused, were being killed, and crimes were being committed," said Weidenfeld, who is co-chair of the Louisiana Nursing Home Working Group, a team of federal and state agencies that investigates poor care. 

In the 1970s, doctors diagnosed so many children with unexplained head injuries that medical journals of the period were writing about spontaneous subdural hematomas - bleeding under the lining of the brain. 

"They called it spontaneous because they just happened without any clinical reason for it," said Dr. Patricia McFeeley, New Mexico's assistant chief medical investigator. "Everyone believed they developed naturally. 

"It wasn't until medical, law enforcement and death-investigation professionals realized that these fatal bleeds were being caused by violence, that these children were not dying of natural causes, but were being killed, did we change the way we handle these deaths," McFeeley said. "This is what we must do with the elderly. We can't trust the old system to catch these deaths." 

Deficiencies are rampant 

About 3 million people a year pass through America's 17,000 nursing homes. Patients occupy about 1.8 million beds on any given day; most are white women who are at least 75 years old. 

Many of the 1.3 million cooks, janitors, administrators, nurses - the majority working for near poverty-level wages - treat their jobs as a calling to ease the pain and safeguard the dignity of their charges. 

But it is the homes and workers that don't perform up to standard that concern most of the 700 professionals interviewed by the Post-Dispatch for this series. They include nurses, researchers, physicians, patient advocates, death investigators, nursing home operators, prosecutors and federal, local and congressional investigators. 

In their eyes, government regulators are losing the war - and in some cases, not even fighting the battle - of preventing negligent deaths of the elderly.

They tell of state investigators failing to ensure safe care in homes; of government-mandated ombudsmen being prevented from intervening; and of federal regulators unable to do much about it. 

These experts attribute the negligent deaths, in most cases, to inadequate numbers of nurses and aides on hand to provide basic, life-sustaining care. The detection of these deaths, they say, is often thwarted by state nursing home inspectors who fail to see - or act upon - the warning signs. The experts complain that law enforcement authorities are rarely notified of deaths by neglect and that coroners and medical examiners are seldom called. 

Collin Wong, a California deputy attorney general who heads his boss's aggressive program to halt wrongful nursing home deaths, said that killings by neglect often are overlooked because "too many people shrug it off by saying, 'Old people die. So what.' 

"This is not to say that every death in a nursing home should be treated as a homicide and every injury as an assault," Wong continued. "But at the same time, these deaths shouldn't automatically be chalked up to old age and natural causes. This is a major faulty perception that is allowing this pervasive neglect, these homicides, to continue." 

Many deaths are called criminal

"It's homicide. Don't sugarcoat it," says Dr. Vincent Di Maio, the medical examiner for San Antonio. He has extensively researched negligent deaths in nursing homes. 

"Enormous numbers of patients are being killed in nursing homes throughout the country because the administrators or the corporate executives order the staffing reduced to the point where the staff cannot provide the promised care that's needed for their patients to survive," he said. 

Some prosecutors agree. 

Finding that regulatory fines and bureaucratic sanctions have had minimal impact on reducing dangerously poor care, a small but increasing number of prosecutors have brought homicide charges. They've targeted nurses and aides found to be responsible for the deadly care and nursing home operators and corporate officials who fail to employ enough nurses to prevent these deaths. 

Prosecutors gained allies among some state regulators who also are calling for criminal charges when death by neglect is confirmed. 

"If it can be proven that the failure to feed, hydrate or properly care for wounds led to deaths in nursing homes, they should be considered as potential homicides and turned over to law enforcement for criminal investigation," said Darrell Hendrickson, Missouri's new deputy director of the Division of Health Standards and Licensure. 

In Hawaii, Indiana, California and Tennessee, district attorneys, county prosecutors and state attorneys general have brought some charges of homicide for nursing home deaths by neglect over the past three years. But they number fewer than a dozen. 

In Pennsylvania, Louisiana, Virginia, Florida, Kentucky and Missouri, U.S. attorneys have used a Civil War-era law to bring federal civil charges in these types of deaths.

Each year, thousands of allegations of wrongful deaths in nursing homes are brought in courtrooms across the nation by aggrieved family members. Court records show that most of these cases result in judgments against the nursing homes or pretrial settlements. But many judgments are sealed, which prevents the public and state regulators from finding out about the offending nursing home. 

Misleading death certificates 

The widespread undercounting of deaths attributed to the three preventable conditions is due mainly to the lack of accuracy - or what some investigators contend is intentional deception - exercised by doctors in filling out death certificates. Many are signed by physicians who have never seen the body. 

"I see a lot of death certificates signed with myocardial infarction, which means: 'I don't have a clue because I wasn't there when the person died,'" said Dr. John Morley, a St. Louis University gerontologist. 

Jeanie Keyser-Jones, a professor in medical anthropology at the University of California at San Francisco School of Medicine and a nationally recognized expert in nursing care, said: "Far too many death certificates list the cause as cardiac arrest, but that's (usually) a wastebasket diagnosis because obviously, everybody's heart stops when they die." 

In January, the Indiana health department processed a death certificate that attributed to natural causes the death of an 80-year-old woman from respiratory problems and cardiac failure. That surprised the Evansville coroner's office, which, after an extensive examination and an autopsy, had just ruled the woman's death a homicide. The coroner said death was caused by severe dehydration. Nursing home records gave no indication that the woman had been fed or given liquid for days, he said. No sign of heart damage was found. 

No one in Missouri signed more death certificates in the past four years citing malnutrition as the cause than Dr. Constantino Carpio. 

Of the 242 malnutrition deaths in nursing homes listed in Missouri records during that period, the health department's vital statistics database of death information shows that Carpio signed 46. 

But he denies it. 

"I never sign malnutrition. I always put down bronchial pneumonia as the cause of death," said Carpio, who said he cared for 500 patients in 11 nursing homes around Troy, Mo. 

When asked why, he answered: "That's what the textbooks say old people die of. You can look it up." 

When Charlotte Gregory, 78, died in September 2001 in the Meadowood Nursing Center in Clear Lake, Calif., court depositions show employees tried to persuade two different physicians to list her cause of death as heart disease. Both refused, saying there was no evidence that heart failure had killed Gregory. An autopsy demanded by her family showed she had died from infection from a ruptured colon aggravated by dehydration and a misplaced feeding tube. 

"It's murder," Dr. Marvin Sando, Gregory's son-in-law and a retired physician, said when he saw the autopsy results. "Whether it was unintentional or through indifference, a preventable death occurred, and it's still homicide." 

The district attorney's office in California's Lake County says it is examining the evidence in the case. 

Without a public outcry for reform, the outcome is predictable, say advocates for the elderly. 

"If you don't feed somebody, they will die. If people aren't given adequate liquids, they will die. If an elderly person's major infection isn't treated, they will die," said Candace Heisler, who retired after 25 years of handling abuse and neglect investigations as an assistant district attorney in San Francisco. She works as a consultant to law enforcement and lawyers. 

"Bad care is often as deadly as having a knife in your hand and aiming it at their heart." 
 

They died painful, preventable deaths and left behind families tormented by their loss. 

They are victims of poor care in nursing homes, a cross section cut from the fabric of America - mothers and fathers, war heroes and homemakers, black and white. 

The survivors now not only grieve for their loss but also struggle with misdirected guilt over whether they could have prevented the deaths. 

Four of these families sought justice in courts of law and received cash settlements from nursing homes. The settlements required that the names of the homes and the amounts of money paid be kept secret. So, those homes are not identified on this page. In the fifth case, criminal charges are pending. 

Despite the settlements, family members say, the tragedies took an emotional toll that can't be soothed by dollars. 

The five stories: 

Alisa Riley is haunted by childhood memories of her mother telling friends, "Don't worry, I know Alisa would never put me in a nursing home." 

But when her mother's Alzheimer's disease progressed to where she needed constant care, Riley had no choice. 

"She always did so much for me," said Riley, an only child who was doted on by her mother, Martha Alice Anderson. 

Riley said: "Not only do I have all this guilt about putting her in a nursing home, but look what happened to her. The last months of her life were horrible." 

When Riley, a registered nurse, complained to the staff at a St. Clair County nursing home that her bedridden mother was dehydrated and malnourished, the response stunned her. 

"All the Alzheimer's patients starve to death, what do you expect," Riley said they replied. 

Her response was indignant. "My mother is not going to die of starvation," Riley said she told the staff. But with no one to assist Anderson, her food tray frequently went untouched. 

"The only time she ate is when I fed her," Riley said. 

Eventually a student nurse, who made training rounds at the nursing home, pulled Riley aside to warn her of her mother's dire condition. 

"She told me that my mother's bed was always drenched in urine and that she was always caked in feces when they made rounds in the morning," Riley said. 

A bedsore on her hip had tunneled to the bone. The nursing student told Riley the conditions should be reported to state officials. Riley called state inspectors the next day and removed her mother from the home. But the damage was done. Anderson, 91, died March 13, 1998, from sepsis, an infection caused by the bedsore. 

For Angie Mynatt, the anguish began with a telephone call on a Sunday afternoon in January. She needed only a few minutes to drive to the nearby Westpark Rehabilitation Center in Evansville, Ind., where her grandmother was struggling for her life. 

"I knew something wasn't right just by looking at her," Mynatt said of her 80-year-old grandmother, whom she found gasping for air. 

Alarmed at her grandmother's condition, Mynatt began to quiz the staff. She asked a nurse's aide when her grandmother last ate or drank and was told three days before. 

"She didn't tell me why," Mynatt said. 

At Angie's demand, an ambulance soon arrived and whisked Mary Mynatt to the hospital, where doctors tried to push fluids into her severely dehydrated body. 

Early the next morning, she went into cardiac arrest and doctors placed her on a ventilator. Later that day, her kidneys began to fail and the tips of her fingers and toes began to turn black and blue from a lack of oxygen. She died that evening. 

Angie brought a flower arrangement for the funeral a few days later. A ribbon that ran down the center carried a written vow from Angie regarding her grandmother's death. "I will solve the puzzle," the ribbon read. 

An autopsy report stated the cause of death as "fluid and electrolyte imbalance due to clinical dehydration." Mynatt had been deprived of fluids for at least two days before being admitted to the hospital. 

The coroner ruled the death a homicide. State regulators later cited the facility for several serious deficiencies. According to a state report, the staff failed to assess changes in Mynatt's eating habits or notify a physician. 

One employee was quoted as telling a state health surveyor: "A lot of people here don't eat, and we don't report it to anyone." 

The words still sting Angie Mynatt, who grew up just down the road from her grandparents' horse farm. 

"No one deserves to die the way that she did," Mynatt said. "She was tortured. She couldn't defend herself. They just let her lie there." 

Conan Smith walked into a nursing home in Illinois' Franklin County in November 1998 for what his family thought would be a temporary stay while his wife, Jo Ann, recovered from hip surgery. 

A nursing home assessment done that day described Smith, 74, as alert, friendly, cooperative and able to communicate clearly. As a belly gunner on a B-17 during World War II, Smith survived being shot down and trapped behind enemy lines in German-occupied Austria and a tour in the Pacific. At age 65, he ran a half-marathon and averaged six-minute miles. 

"We tried to go down once every two weeks to see Daddy," said his daughter, Lana Stringer, who lived hundreds of miles away in southern Indiana. "I just put it in their hands and trusted them that everything was going to be fine and he was going to be cared for properly. As I look back, we should have stripped him down and looked at every part of his body." 

At one point, Smith lost 30 pounds in 30 days and soon could no longer walk. He also began developing bedsores, one of which would tunnel from his buttocks almost completely through to his groin. 

The nursing home finally notified family members of his rapidly declining condition the night before he was admitted to a hospital comatose and suffering from gross septic shock. 

His poor care and filthy condition stunned hospital staff members. Smith had not just one bedsore as the nursing home had told the family; he had three, and gangrene was ravaging his body. He died from septic shock four days later, five months after he entered the home. 

"People should be aware when they do put their loved one in a nursing home, don't think your hands are freed from anything," Stringer said. "You've got to be there and check them out and know what's going on." 

Charlotte Gregory, 78, recovered well enough from gallbladder surgery to be moved to a nursing home nearer her home and relatives in Clear Lake, Calif., last year. 

Sixteen days later she died, her death due to a bowel impaction aggravated by dehydration. Nursing notes during her stay made frequent references to Gregory's dehydration, but staff members failed to follow their own procedures and doctors' orders regarding her treatment. The notes from Gregory's final hours failed to identify anything greatly out of the ordinary, even though she was in severe pain and family members eventually insisted that a doctor be called. A nurse's aide later testified that the facility was short staffed. 

"When I read a copy of the autopsy I almost threw up," said her son-in-law, Dr. Marvin Sando, a retired physician. "I can't tell you the emotions that went screaming through my head. I was angry, shocked, disappointed, sick to my stomach. I was just morally shocked that a woman in this day and age could have this kind of death. It was horrific. It still bothers me that someone could die like that." 

Fermon Burton, the first black Golden Gloves champion in the Kansas City area, moved into a nursing home on July 13, 1998. Burton was rail thin, 6 feet 8 inches tall and 155 pounds. A nurse at the Kansas City home that day assessed him as being a high risk for skin breakdown. The warning did little good. 

On her almost daily visits, his wife, Mary Burton, often found her husband lying in urine-soaked sheets while staff members sat in another room laughing and enjoying soft drinks, she said. Seven months after entering the home, he began developing bedsores. By the time he left the home to enter a wound care center, he had five infected bedsores. 

"You could put a fist in those sores," Mary Burton said. "He was gone too far." 

He died Jan. 13, 2000, as a result of sepsis. He was 86. 

Today, Mary Burton often sits alone in her apartment surrounded by photographs of the God-fearing man she loved. 

"It's just sad that people have to die like that - from a lack of attention," Burton said. "I don't think I will ever put it behind me."