Casey Shively holds a photograph of a household ski journey along with his sister, Katie, and his father, Dan, in 1996. Dan Shively died in a reminiscence care dwelling after being violently attacked by one other resident.
Jessica Plance; snowboarding picture by Crystal Pictures Images/KFF Well being Information
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Jessica Plance; snowboarding picture by Crystal Pictures Images/KFF Well being Information
Dan Shively had been a financial institution president who constructed floats for July Fourth parades in Cody, Wyo., 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 Neighborhood in Billings, Mont., each had been deep within the grips of dementia and exhibiting among the illness’s horrible traits.
Shively had been wandering misplaced in his neighborhood, having outbursts at dwelling, and leaving the gasoline range on. Dowd beforehand had been hospitalized for being confused, suicidal, and agitated, medical information filed in U.S. District Courtroom in Billings present. When Dowd entered Canyon Creek, managers warned staff in a be aware later filed in court docket that he might be “bodily/verbally abusive when annoyed.”
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 advised Shively to maintain the knife away from his espresso, in response to a witness assertion filed in court docket. 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 onerous that when he hit the ground, his cranium fractured and mind hemorrhaged, in response to a lawsuit his household filed towards Canyon Creek.
“The physician mentioned there’s not a lot they might do about it,” his son Casey Shively mentioned 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 response to facility information filed within the court docket case. His anger would flare shortly. “I’m actually scared to dying of Jeff,” one nurse wrote in a filed assertion describing Dowd’s dispute with one other resident.
In court docket, Canyon Creek denied legal responsibility for Shively’s dying. Its privately held company proprietor, Koelsch Communities, declined to reply questions from KFF Well being Information. Chase Salyers, Koelsch’s director of promoting, mentioned 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 family mentioned in a press release by way of textual content they’d not remark as a result of they’d no firsthand data. “We had 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 amenities are alarmingly widespread. 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 eliminated an oxygen masks.
A current examine 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 dwelling residents engaged in bodily aggression or abuse towards residents or workers members inside one month. Dementia residents are particularly possible to be concerned in altercations as a result of the illness damages the components of the mind affecting reminiscence, language, reasoning, and social habits.
Greater than 900,000 individualswith Alzheimer’s or different forms of dementia reside in nursing properties and assisted dwelling facilities. Lots of the most critically impaired dwell within the roughly 5,000 amenities with locked dementia flooring or wings or the three,300 properties devoted solely to reminiscence care. These locations are largely for-profit and sometimes cost hundreds of {dollars} additional a month, promising experience within the illness and a protected atmosphere.
Casey Shively says that as his father’s dementia worsened, it turned tougher for the household to deal with him at dwelling. “He would begin strolling the neighborhood and get misplaced,” Shively says. “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.”
Jessica Plance
/KFF Well being Information
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Jessica Plance
/KFF Well being Information
Clashes could be spontaneous and too unpredictable to forestall. However the probability of an altercation will increase when reminiscence care properties admit and retain residents they’ll’t handle, in response to a KFF Well being Information examination of inspection and court docket 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 preserve them regardless of demonstrated threats to others.
“As a lot as long-term care suppliers on the whole do their finest to supply competent, high-quality care, there’s a actual downside with endemic violence,” mentioned Karl Pillemer, a gerontologist at Cornell College and lead creator of the JAMA examine.
“There must be far more of an effort to single out verbal and bodily aggression that happens in long-term care,” he mentioned, “and start to create a mannequin of violence-free zones in the identical means we’ve got violence-free zones within the faculties.”
A hazard to others
The primary indicators of Shively’s vascular dementia emerged in 2011 as confusion, however the illness accelerated in 2016, in response to interviews along with his spouse and youngsters and his medical information. He started referring to mountains he knew effectively by the fallacious title and forgot tips on how to tie flies on his fishing line. “The decline was so sluggish at first we thought we may handle,” his spouse, Tana Shively, mentioned in an interview earlier than her dying this yr.
Because the illness progressed, his outbursts turned onerous to deal with. He took a swing at one in every of his sons when upset in regards to the temperature in the home. He refused to swallow his medicines and fell repeatedly.
“He would begin strolling the neighborhood and get misplaced,” Casey mentioned. “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 dwelling and had a protracted historical past of dementia with behavioral points, main depressive dysfunction with psychotic options, and hypertension, in response to medical information filed in court docket. Dowd entered Canyon Creek in October 2018 to be nearer to his brother, who lived close by in Wyoming, in response to an admission discover the ability offered to staff that was included within the court docket file. The discover mentioned Dowd suffered from dementia attributable to extreme and long-term alcohol use.
Two months later, Shively moved in.
Montana licenses Canyon Creek, which has 67 beds, as a Degree C assisted dwelling facility, which allows it to accommodate individuals with cognitive impairments so extreme that they can’t specific their wants or make primary care choices. Montana regulation says these amenities can not admit or retain a resident who’s “a hazard to self or others.”
Within the lawsuit, Shively’s household argued that on condition that regulation, Canyon Creek by no means ought to have accepted or saved Dowd. The Shively household’s lawyer, Torger Oaas, famous in court docket papers that Canyon Creek’s consumption evaluation type for Dowd categorized his habits as “bodily and/or verbally abusive/aggressive 1x per 30 days.” Oaas additionally wrote in court docket 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 mentioned the Montana statute was too broad to be the idea of a negligence declare and argued that each 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 mentioned. “The accident was not moderately 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 telephone and “do your job,” a nurse wrote in a logbook entry filed in court docket.
“He obtained into my face,” the nurse wrote. “It seemed like he was going to hit me — he had his hand/fist raised.”
Canyon Creek Reminiscence Care Neighborhood in Billings, Mont., the place Dan Shively died, is licensed as a Degree C assisted dwelling facility. Degree C amenities are permitted to accommodate individuals with cognitive impairments so extreme that they can’t specific their wants or make primary care choices.
Jessica Plance for KFF Well being Information
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Jessica Plance for KFF Well being Information
“As dangerous as I’ve ever seen it”
Folks with dementia will lash out as a result of they not have social inhibitions or as a result of it’s the one means they’ll specific ache, discomfort, concern, disagreement, or nervousness. Some widespread triggers — overstimulation from loud noises, a frenzied ambiance, unfamiliar faces — are hallmarks of dementia care establishments.
“We will’t count on somebody who is continually and unfailingly disoriented to adapt to the environment anymore,” mentioned Tracy Wharton, a licensed medical social employee and dementia researcher in Florida. “Now we have to adapt to them.”
Eilon Caspi, a College of Connecticut researcher, analyzed 105 deadly incidents involving dementia residents and located 44% had been deadly falls during which one resident pushed one other. “Some individuals are aggressive, and a few are violent,” Caspi mentioned, “however should you look intently, the overwhelming majority are doing their finest whereas dwelling with a severe mind illness.”
Holly Harmon, a senior vice chairman on the American Well being Care Affiliation/Nationwide Heart for Assisted Dwelling, an trade commerce group, mentioned in a written assertion that conflicts can not at all times be averted regardless of facility operators’ finest efforts. “In the event that they do happen,” she mentioned, “suppliers reply promptly with interventions to guard the residents and workers and stop future occurrences.”
However Richard Mollot, government director of the Lengthy Time period Care Neighborhood Coalition, a resident advocacy group, mentioned many operators of assisted dwelling facilities, together with reminiscence care models, are pushed by the underside line. “The problem that we see very often is that assisted dwelling retains individuals they need to not,” Mollot mentioned. “They don’t have the staffing or the competency or the construction to supply protected care.” Conversely, he mentioned, when amenities have sufficient rooms full of paying clients, they’re extra more likely to evict residents who require an excessive amount of consideration.
“They are going to kick them out in the event that they’re too cumbersome,” Mollot mentioned.
Teepa Snow, an occupational therapist who based Optimistic Method to Care, an organization that trains dementia caregivers, famous that the house inside many amenities, with double rooms, tight widespread areas and restricted out of doors entry, can gas conflicts. She mentioned 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 dangerous as I’ve ever seen it,” she mentioned.
“Quite common matches of rage”
The next account of Dowd’s time at Canyon Creek is predicated on 44 pages of nurse’s notes, witness statements, and inside resident-on-resident altercation stories; all had been contained within the facility’s information and filed as reveals within the court docket case. After Shively’s dying in December 2018, Dowd was given new prescriptions, though the court docket file is unclear if the change was due to Shively’s dying. Nonetheless, the information present, Canyon Creek was unable to go off recurring altercations involving Dowd.
Some had been verbal threats. As soon as, Dowd yelled at residents in the lounge to close up, known as them “retards” and advised 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 response to 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 advised him to close up. Based on a witness assertion, as a nurse took the resident to the lavatory, Dowd muttered beneath his breath: “Stuff his head in the bathroom.”
Different conflicts had been bodily. Dowd shoved a resident “down on his again so onerous his head bounced off the ground,” a nurse recorded in a be aware. In a unique 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 top, as soon as inflicting bleeding, in response to two resident altercation stories.
The notes element that Dowd was not at all times the initiator. As soon as, Dowd’s roommate scratched and punched him after Dowd advised him to make use of the bathroom reasonably than pee on the ground, leading to a struggle. Caregivers separated the 2. One other day, a resident named Invoice wandered into Dowd’s room and pulled Dowd’s hair and beard. Dowd advised the nurses he “felt unsafe and VERY indignant,” a nurse’s be aware mentioned. 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 saved 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 state of affairs. I’m actually scared to dying of Jeff. I’m scared to strategy him and speak to him when he will get into these quite common matches 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 combating 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 clarify it was inappropriate to harm others,” one nurse wrote after one incident.
Salyers, the corporate advertising director, mentioned in his e-mail that the employees at Canyon Creek and different Koelsch amenities are “extremely certified” and “extensively skilled.” He mentioned the corporate’s reminiscence care communities are “distinctively designed and staffed” for individuals with Alzheimer’s and different types of dementia.
“It’s good to have a girlfriend”
The nursing notes and statements within the court docket file counsel that incidents had been frequent sufficient that nurses commented on Dowd’s occasional serenity. “No agitated or aggressive behaviors this shift,” one be aware mentioned. One other nurse be aware mentioned 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 youthful females” — or ambiguous, comparable to putting 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 mentioned. When nurses caught the habits, they separated these concerned and rebuked Dowd. A workers member wrote in a press release that Dowd was inappropriate all through her shift, making sexual jokes and “attempting to seize me.”
Based on nursing notes, in summer time 2021, Dowd advised one feminine resident he wished 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 beneath her shirt and pants. The caregiver advised Dowd to “cease it and never ever try this once more” and introduced the lady out to satisfy 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 response to a nurse administrator’s testimony in a deposition filed in court docket. The nurse testified Dowd was not at Canyon Creek. That’s the final point out of Dowd’s whereabouts within the public file. A spokesperson for the Montana Division of Public Well being and Human Companies, which oversees the hospital, wouldn’t verify whether or not he was a affected person.
At a pretrial listening to, the decide excluded dialogue about Dowd’s altercations after Shively’s dying. In a court docket submitting, Shively’s lawyer requested permission to share proof with the jury that Canyon Creek gave its government director a bonus any month when 90% or extra of the beds had been crammed so he may argue Canyon Creek had a monetary motivation to confess Dowd. However the decide additionally barred that info from the trial, which Canyon Creek mentioned in a court docket 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 dying. It awarded the household $310,000.
“For us, the cash wasn’t an enormous issue,” mentioned Spencer Shively, one other of Dan Shively’s sons, who known as the damages so modest as to be a victory for Canyon Creek or its insurer. “No less than they had been negligent per se. However I don’t realize it actually modified something. For me, I obtained some closure. I really feel like these amenities are simply persevering with to do the identical issues they’re going to do as a result of there hasn’t been systemic change.”
KFF Well being Information is a nationwide newsroom that produces in-depth journalism about well being points and is likely one of the core working packages at KFF — an impartial supply for well being coverage analysis, polling, and journalism.
