Neglected to Death

NEGLECTED TO DEATH | Part 1: Toxic sore fatally undetected

Theodore and Dorothy Archer retired to sleepy Hernando County in 1981, but never really settled down. For the next 20 years, the Archers did the Lord’s work, driving a recreational vehicle from Florida to Canada, California to Maine, renovating churches with a group called Servants on Wheels.

It was the sudden onset of Alzheimer’s disease that finally slowed Dorothy Archer.

Unable to cope with his wife’s forgetfulness and agitation, Theodore Archer moved her to a nearby assisted-living facility called Edwinola Manor in late 2008. There, he thought, she would get the care and service she had given so selflessly as a church outreach worker.

Instead, nurses failed to treat a gaping pressure sore on her lower back that filled her body with raging toxins.

“There is no valid reason for such a wound developing undetected in an ALF resident,” wrote Tim McClain, a registered nurse who investigated the case for the state Department of Children & Families.

Archer, 90, was not the first Edwinola resident to fall victim to shoddy care.

In April 2008, Carmen DeArmas was hospitalized with a rotting, oozing foot, requiring immediate surgery. Family members told investigators the injury was so bad, the 79-year-old woman’s sock was “embedded into the skin,” a DCF report says.

Two months later, Edwinola administrators told the Agency for Health Care Administration they had retrained workers to better recognize and report signs that residents’ health had deteriorated.

But in October that year more problems emerged: AHCA found the home had failed to keep records on three more residents whose health had deteriorated — including one whose pressure sore was severe enough to force a hospital stay.

Once again, Edwinola administrators submitted a detailed plan for doing better.

The plan had just been put in place when Dorothy Archer was admitted to the retirement home, diagnosed with acute psychosis — the result of a quickly progressing case of dementia.

The Archers had been inseparable for 37 years, living in the Philippines, Hawaii, South Africa, Panama, Virginia and a host of other places where Theodore’s second career as a combustion engineer took him.

“We were always together,’’ Theodore Archer said. “Everywhere I went, she was with me.’’

The couple had planned to grow old together — and die together.

But the retired naval chief petty officer — who survived the sinking of the USS Hornet at the Pacific battle of Santa Cruz in 1942 — was no match for his wife’s Alzheimer’s.

Confused and agitated, Archer had been hospitalized under Florida’s involuntary commitment law when a neighbor suggested Edwinola, a 170-bed home in Dade City, just north of Tampa Bay. Archer said he visited his wife every day — usually more than once.

Medical notes suggest Archer was faring well in the facility until March, when nurses feared a raspy cough might be the first signs of pneumonia.

When Archer was sent to a nearby hospital for treatment, the home’s notes documented only a “small” skin lesion, described two days earlier as a “red area” on her lower back.

But doctors immediately said the home’s description of the wound was far from accurate. The festering sore, as large as a grapefruit, had become so infected it had turned black — and her kidney was failing, said Dr. Keith Rosenbach at Pasco Regional Medical Center.

“The poison is all throughout her body. There’s no way I can save her,’’ her husband said he was told by a doctor.

Archer was transferred to a local hospice. Aides cleaned her, and put on a crisp new gown. Within 30 minutes, she was dead.

After her death in 2009, state investigators questioned the home’s treatment of Archer’s blackened sore.

“It is obvious that ALF staff should have noticed the buttock wound,’’ McClain, the DCF nurse, wrote. “It is also clear that there was a serious systemic failure at the ALF.’’ Archer, he concluded, “was inadequately supervised and medically neglected.”

Janice Merrill, an Orlando attorney who represents Edwinola, declined to comment, citing ongoing litigation.

Even after Archer died, the problems at Edwinola continued.

A month after her death, a woman was hospitalized with bruises on her arm, wrist, chest and buttocks. Doctors discovered she had been given so high a dose of blood-thinners that she needed several transfusions. She also had been given three pain patches — triple the dose prescribed by her doctor.

The woman, a DCF investigator wrote, had been “overmedicated to the point of losing consciousness.’’

During the investigation, the home’s director of nursing resigned. The facility once again told state agents it had “incorporated new safety measures and training to prevent recurrence,” DCF records show.

But in November 2010, regulators found more breakdowns — this time, after relatives complained a resident of the home was “acting strangely and no one knew why.” When inspectors showed up, they found the home had failed to give the resident crucial psychiatric and heart medications.

Once again, Edwinola promised to retrain its workers to make sure the problems didn’t happen again, records state.

For Theodore Archer, 91, who is suing the home, learning that the facility had been warned twice before his wife’s death to pay better attention to residents’ health has made his loneliness even more difficult.

“Miss her? God, yes,’’ Archer said. “I guess it’ll be a long time missing her till I go.’’