2004-02-06 / Front Page

Insider Says Understaffing Killed Grandmother

By Brian Magoolaghan
Insider Says Understaffing Killed Grandmother By Brian Magoolaghan


Lillie GardnerLillie Gardner

An insider at the nursing home where an elderly woman died of hypothermia Tuesday night said the staff made a series of blunders that led to the woman’s death – because they were short-handed.

The employee of the Bishop Charles Waldo MacLean Nurs ing Home, who requested anonymity, spoke with The Wave on Wednesday.

The employee was working Tuesday night and participated in the search for 79-year-old Lillie Gardner, a mother of six with 14 grandchildren. Gardner was found on the roof, which had become a frigid pool of rainwater and snow.

Gardner’s family has accus ed the nursing home of negligence, and the city’s Depart ment of Health and Mental Hy giene and other agencies have launched investigations to determine what happened.

There were only three aides, each assigned to about 15 patients, working the p.m. shift, according to the employee. Gardner was placed in room 518, bed A, next to the door to the hallway.

"You’re not supposed to have wandering patients near doors," the employee said.

Gardner was fed her supper at 4 p.m. At about 6:30 p.m. a staff worker heard the alarm that is triggered when the door to the roof is opened, but didn’t recognize it and might have disabled it, according to the employee.

Reports from other news sources say nursing home workers heard and res ponded to the alarm, but didn’t see the elderly woman.

Gardner was discovered missing at 9 p.m., when staff tried to administer her medication.

Melissa Krantz, a spoke s person for the nursing home confirmed that Gardner went for an "unsupervised walk" at a yet-to-be-determined time. Krantz explained that nursing homes have to balance supervision and the resident’s self respect.

"It’s not a prison," said Krantz, who described the death as an "unfortunate situation."

Gardner climbed two sets of six stairs separated by a landing to reach the roof. She was reportedly in the beginning stages of Alzheimer’s.

A room-by-room search, including bathrooms and closets began shortly after 9 p.m. Someone eventually checked the roof, but the area where Gardner would later be found was not in view from the door. The roof was dark and its drains were blocked by snow and ice. The rainwater had become several inches deep.

"Nobody wants to stick their foot into the ice-cold water at night," the employee said candidly, suggesting why a more thorough search of the roof hadn’t happened sooner.

The police were called at about 12:11 a.m. Gardner was found 20 minutes later and was rushed to St. John’s Episcopal Hospital emergency room by way of a connecting bridge. She was pronounced dead at 1 a.m.

The employee said that in recent months the nursing home has been understaffed and lacked necessary equipment due to spending cuts, and added that there are other problems there such as missing medication.

"The staff is not happy, and if the staff is not happy the work can’t be done," the employee said.

Krantz would not comment on whether the nursing home was understaffed or speculate on whether the police should have been called sooner.

"An investigation will answer the unanswered questions," Krantz said.


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