A total of 10 civil penalties and 6 citations have been filed against the Avamere facility in 13 months
by: Vern Uyetake, Judy Hurliman, a Portland woman, talks about her father William Balmer, who died of renal failure after becoming dehydrated at the Pearl at Kruse Way, an Avamere facility for rehab and dementia.

His love of logging began early, at the age of 13, when he lied about his age and took a job towing timber on horseback.

By the time William Balmer was 93, his life had followed a similar path of hard work and endurance. He survived a tour in World War II, a job welding ships in the Portland harbor and, later, a career running the Balmer Logging Co.

So when Balmer fell in his home in Hebo, Ore. on June 10, 2006, and hit his head on a dresser, he also survived a severe injury.

After traveling by helicopter to Portland for brain surgery, he recovered from the procedure, and also successfully fought a viral infection contracted at the hospital.

Aug. 4, he entered Avamere Pearl at Kruse Way rehab facility in Lake Oswego with plans to return home.

Instead, he died just three weeks later and what killed him wasn't his head injury or his infection.

He died after becoming so dehydrated at the Pearl that his kidneys failed.

Man dies of dehydration

Judy Hurliman, Balmer's daughter, sat in a chair in her Ladd's Addition living room and told the story of his death.

Using a three-ring binder stuffed with Balmer's medical records and complaints to the Oregon Department of Human Services, Hurliman alleges a course of medical errors, neglect and backdated record keeping at the Pearl, things she believes cost her father his life.

In the three weeks her father was treated at the Pearl, Hurliman said she noted a number of unexplained cuts and bruises. She said the facility seemed understaffed, employees changed almost daily and the Pearl failed to notify her and her siblings after their father fell out of a wheelchair while unattended.

While Balmer was alert during most of his stay at the Pearl, Hurliman said, he was difficult to understand because of a recent tracheotomy and was seeing a speech therapist. Overall, his condition seemed to improve.

But Aug. 19, Hurliman said the family suspected problems.

'Dad was not acting right. He was groggy, lethargic, not talking right, not doing any of the things he had done before,' she said.

The following day, Hurliman said she and her siblings found their father slumped in a wheelchair facing a blank white wall in his room.

His condition appeared to be worse. His children expressed concern about his swollen legs and noticed unexplained abrasions on his leg. Hurliman and her brother and sister shut the door and asked Balmer if he was being abused.

The man, who needed help to eat and was incontinent, lowered his eyes several times. Doctors at Legacy Meridian Park Hospital, where he was later treated, ultimately found his back and thighs covered in bedsores. Medical records and photos taken by police paint a painful picture.

But in his room at the Pearl, Balmer's children struggled to understand his problem. They suspected he was overmedicated and talked privately about placing a camera in the room. They tried to formulate a plan for the following day and, later, talked to a nurse about the swelling in his legs. Balmer was given a diuretic for the problem.

The following day, after Balmer was taken to the hospital by ambulance, doctors found his kidneys had failed for lack of water, according to medical records and police reports. Tests also showed toxic levels of a drug called Dilantin, used to treat seizures.

Balmer's children faced a terrible choice: To let him take fluids and drown or let him die, slowly, of dehydration.

'It was a terrible decision to have to make. It was a terrible death,' Hurliman said.

Balmer died after being given morphine for 24 hours. He died alert after saying goodbye to his family, including his wife of 73 years, his four adult children and some of his dozens of grandchildren and great grandchildren.

'He hugged everybody and told them he loved them. He knew. Dr. Ash, the neurologist, said he was very aware,' Hurliman said.

'It was like us killing him but it wasn't us … That's the impact those people don't understand, having to be in a room with somebody for days, slowly turning up the morphine so they will die. We shouldn't have to do things like that.'

When asked about Balmer's death, Avamere officials said they did not know the man had died. Balmer's dehydration resulted in the only federal penalty against the facility since it opened. Oregon Department of Human Services enforces federal standards at nursing homes and residential care facilities.

Saying she was unable to comment without reviewing the medical records, attorney Deborah Nedelcove, vice president of risk management for Avamere, said police and DHS reports often don't tell the whole story about incidents in care facilities.

'We can't force-feed a resident. We can only get them to take what they are willing to take,' she said.

Hurliman said she believes the facility should have given fluids intravenously. She filed a complaint against a physician at the Pearl with the state board of medical examiners and also plans a lawsuit against Avamere.

Innovation and injury

From the start, backers of Avamere's combined rehab and dementia facility in Lake Oswego called the project innovative.

When it opened in December 2005, the Pearl at Kruse Way was the first skilled nursing home in Lake Oswego in more than a decade.

Sold as an opportunity for local residents to bring aging parents closer to home, the Pearl offered two components under one roof: A rehabilitation center for short-term injuries and residential living for residents with Alzheimer's and dementia.

The 47-bed Memory Care Residence focuses on hospitality, dividing patients into three themed neighborhoods or-ganized as households. They have kit-chens, living rooms and outdoor courtyards and aim to integrate families into day-to-day life. There are nine people currently on a waiting list for the unit.

It is here where the Pearl has earned the majority of sanctions from DHS, most related to medication errors.

There are two separate enforcement actions DHS has at its disposal: Civil penalties for incidents involving residents and citations for violations of federal standards in the facilities.

The citations and penalties at the Pearl outnumber similar complaints at other Avamere facilities in the Portland region. The Pearl has garnered a total of 10 civil penalties and six citations in 13 months.

The 29-bed Rehabilitation Center at the Pearl has had fewer problems with three civil penalties. There are no permanent beds in the center, creating a temporary atmosphere to comfort patients eager to return home.

When Balmer did not return, his death by dehydration resulted in one of the civil penalties levied against the Pearl in its 13 months of operation.

DHS surveyors, who enforce the federal standards, also cited the Pearl six times for failing to meet requirements.

The penalties range from failing to provide a safe medication system and failing to administer medicine as ordered to failing to follow doctors' orders and address residents' behavior properly.

In one incident in May, a penalty resulted when the Pearl failed to offer meal supplements to a patient who lost 45 pounds in 12 days.

In another in June, the facility was issued a penalty for failing to get timely medical treatment for a patient infected with gangrene.

Along with Balmer's death, that last incident is one of three in which patients at the Pearl recorded injuries with DHS.

Both Nedelcove and Matt Hilty, CEO of Avamere's skilled nursing and residential care facilities, say the Pearl is doing well overall.

They blame problems on assembling a new staff and an innovative design that allowed patient families to bring in bulk pharmaceuticals. The practice, while cheaper for families, was not as reliable as using punch cards to track medicines. It has since been changed.

Nedelcove said that although the facility has received 10 civil penalties, only three caused harm to patients. The others, she said, were level two violations, a lesser offense.

'Twos mean no harm to the resident,' she said.

'Ultimately all of the facilities would strive to have absolutely no citations … Occasionally systems do need to be worked on.'

Hilty said the Pearl increased staffing levels in the last 60 days.

'I took into account the level and quality of care we want to provide,' he said.

Hilty and Nedelcove say most of their clients are happy and consider the Pearl their home.

Death is 2nd incident involving police

For Lake Oswego Police, the call to investigate Balmer's death at Meridian Park hospital was the second incident involving the Pearl and the second in which DHS would fine the facility for injuring a patient.

In the first incident in April, a nurse at the Pearl called 9-1-1, saying an 87-year-old Alzheimer's patient was agitated, aggressive, threatening and damaging property.

Police who responded took a phone receiver from the woman and held her by her wrists as she collapsed to the floor. She was placed on her stomach and handcuffed. Ultimately, she suffered bruises to her wrists, injury to her knee and a large bruise on her forehead.

The caregivers responsible for the woman at the time said they struggled with her for an hour and a half before police were called. They later told DHS officials they had not received training on working with aggressive behaviors.

The Pearl was eventually fined $300 for failing to respond appropriately to a resident's behavior, a state rule violation.

The woman, Elvera Stephan, and her son, James, filed a lawsuit against Avamere in November and are seeking $56,000 in economic damages and $500,000 in non-economic injuries. They are demanding a jury trial.

The Stephans' lawsuit alleges that James Stephan was told the Pearl had the staffing and the training to handle Alzheimer's behaviors.

Nedelcove said the Pearl does not guarantee keeping a violent patient on site and would not do so, since keeping an agitated Stephan could have endangered other patients.

She said the nurse who called 9-1-1 likely expected police to stand by while EMTs transported Stephan to a hospital. She blamed police for interfering and causing Stephan's injuries.

She said the Pearl has since offered training to police.

$2,750 in penalties

Called out to investigate Balmer's death, a Lake Oswego detective said he found its circumstances unusual but struggled to make an arrest.

'It became very evident early in the investigation that we didn't have allegations against a particular person, we had allegations against a facility,' said Det. Bob Lee.

Lee identified medical conditions causing him to believe Balmer had been neglected, including the bedsores on the man's back and legs.

The report notes statements made to Lee by witnesses did not match the records kept by the Pearl.

He forwarded his investigation to DHS officials, who later conducted their own.

DHS found Balmer suffered renal failure because he was not properly hydrated at the Pearl. The facility was levied with a federal penalty of $1,500, the largest penalty charged to the Pearl yet.

Total fines stemming from the 10 penalties equal $2,750.

Scott Kocher, attorney for Stephan and her son, James, points to the dollar amounts of civil penalties as a major reason injured parties are turning to the courts.

In a lawsuit against Avamere, the Stephans are seeking $56,000 for economic damages stemming from Elvera Stephan's medical care. By contrast, the fine paid by the Pearl for failing to address Stephan's behavior on its own was $300.

The Pearl paid $400 for failing to respond in a timely way to a patient's gangrene.

There was no fine in the case of the patient who lost 45 pounds in 12 days.

'It is our view that when you have large businesses running nursing homes, a $300 fine is not something that's going to get anybody's attention,' Kocher said.

Avamere officials disagree that their industry needs more regulation.

'I think we are much more scrutinized than a private caregiver. A caregiver in someone's home can get away with anything,' Nedelcove said.

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