This is part two in a three-part series. Read part three here. When Alva Trouts earthly remains arrived on March 4, 2007, at the Barbara Falowski funeral home in Fort Lauderdale, the death certificate had already been signed.
Cause of death: Failure to thrive.
But to the funeral home, the death was anything but natural, said relatives: Trouts neck was broken in one place and dislocated in another. Gaping pressure sores ravaged her back and ankle. Instead of preparing her body for a service, the home sent her remains to the Broward County Medical Examiner.
There, an autopsy reached a far different diagnosis: Trout, 93, died of pneumonia brought on by a traumatic injury: Accident, the new death certificate said, with neck fracture.
The case of Trout, who had been living at Williamsburg Landing in Wilton Manors, was among at least three found by The Miami Herald in which death certificates signed by doctors working with ALFs were directly contradicted during state neglect investigations.
In four other cases at other ALFs, the Department of Children & Families found evidence that caretakers falsified records during death cases, but no one was charged.
For investigators and family members, the lack of reliable records creates gaps in understanding what happened to residents in their final days and ultimately, how they died.
To DCF agents looking into the death of Edith Carpenter Layton, the falsification of key drug records concealed just how many powerful narcotics were fed to the 84-year-old during her decline at Crystal Gem ALF.
When Layton checked into the home in Citrus County in April 2007 recovering from broken ribs she was supposed to stay only a few days while her family left town to celebrate her grandsons birthday.
She did not want to ruin the party for the rest of the family, so she agreed to go to the home for a long weekend, said granddaughter Anne Layton Rice of Key West.
Shortly after being dropped off at the home, Layton fell and broke her hip. Caretakers gave her heavy doses of tranquilizers instead of taking her to the hospital.
When Laytons daughter returned to pick up her mother, she found the woman clinging to consciousness, and rushed her to Citrus Memorial Hospital. There, doctors found the elderly woman was extremely sedated and severely dehydrated, records show.
Her condition was so bad that surgeons had to hold off for three days before trying to repair her broken hip. After lingering for several weeks, Layton died from complications arising from the injury.
In the ensuing days, DCF agents reached a startling conclusion: The home had falsified records of medications given to the woman.
Medical logs that were supposed to show the quantity of narcotics given to Layton didnt match the number of pills missing from the facilitys inventory. In addition, signatures on logs were forged.
Even a home administrator suggested the medication log had been made up after Layton left the facility, reports stated.
But in the end, no one was charged. Rich Buxman, an assistant state attorney in Citrus County, said his office found discrepancies in the records and signatures that appeared forged, but those are civil matters, he said. That would be great for a civil case.
However, thats not the case: Under a special provision in Floridas assisted-living facility statute, the changes to the documents are a crime.
Any person who fraudulently alters, defaces or falsifies any medical record or other record of an assisted-living facility faces up to 60 days in jail and a $500 fine, according to the statute.
William Dean, a former Miami-Dade assistant state attorney who now represents claimants in death cases, said prosecutors should have pursued forgery charges.
Because if you dont, what happens the next time? Dean said. Youll do it all the time. You not only send a message that its not going to be tolerated, he added, but it will help protect medical records in future death cases.
Crystal Gems administrator Rebecca Bilby, who took over the facility after Layton died, said the home has made improvements, including rigorous audits of medication logs, but referred questions to the corporate owner. DOS Health Care did not return repeated phone calls.
Shortly after Rose Marie Wheeler died of a severe intestinal infection two years ago at an ALF in Hernando County, investigators faced a similar dilemma.
Key medical records that would have shown whether the home treated the 76-year-old woman at Forest Oaks of Spring Hill had disappeared. Others, investigators found, appeared altered.
When state agents asked to look at the elderly womans health charts, they were told every record was available except for the month when Wheeler was declining and eventually died.
When pressed, the homes manager provided a chart which state agents noted had dark writing that was written over the original printing for several dates.
Whats more, the administrator told a DCF investigator the medication log he requested had been shredded by Hernando-Pasco Hospice workers a charge the hospice vehemently denied.
The investigation shows evidence indicating there may have been an intent by the facility to cover up or alter records to mislead, a DCF agent concluded. In my opinion the records were altered.
Though DCFs findings were sent to the state attorney generals office, agents never arrested anyone for doctoring records, instead focusing on the fact that Wheelers body had already been embalmed and couldnt be autopsied.
The only other agency to investigate the death the Hernando County sheriffs office closed its case weeks before DCF agents even completed their review, never considering the forgeries. The homes administrator did not return repeated phone calls.
Unlike the issue of phony medical records, the case of Alva Trout highlights another problem that conceals the ways that residents die: death certificates signed by house doctors.
Though physicians are granted sweeping powers in Florida when declaring causes of death, only medical examiners are allowed to decide in cases of accidents.
Just days after Dr. Dinh Hoang Quoc Pham declared Trout died from chronic heart disease, an autopsy by the Broward County Medical Examiner showed the woman instead died from complications of a broken neck.
The findings raised questions among family members about Phams assessment and the events that led to the death of the elderly woman, who went nearly 12 hours without medical care after falling at Williamsburg Landing.
I was getting the impression this doctor was trying to force this certificate, son Randy Trout said. DCF later found that Trout broke her neck after falling in her room at night, and languished for hours until the home called the family.
By the time she was taken to the hospital, she was screaming in pain, according to medical records. She died a month later.
Randy Trout questioned why Pham would sign a death certificate saying his mother died from heart disease.
I dont know why theyre telling us she had a heart attack, Trout said.
Later, the death certificate signed by Pham was rejected by the medical examiners office in favor of the new one saying Trout had died from pneumonia brought about by a broken neck.
Pham, whose medical group treated residents of Williamsburg Landing at the time, did not return repeated phone calls from The Miami Herald. Ralph Marrinson, president of the company that owns the facility, referred questions to his attorney.
Rick Wolfe, a Miami attorney who represents the home, said he disagreed with the medical examiners findings, but would not elaborate.
Randy Trout, whose family is now suing the facility, said his mother was in so much pain when she arrived at the hospital, she could barely be touched. She was screaming so badly, he said. They had to cut the clothing off her.