Dan Shively had been a financial institution president who constructed floats for July Fourth parades in Cody, Wyoming, and adored fly-fishing together 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 Group in Billings, Montana, each had been deep within the grips of dementia and exhibiting a number of the illness’s horrible traits.
Shively had been wandering misplaced in his neighborhood, having outbursts at house, and leaving the gasoline range on. Dowd beforehand had been hospitalized for being confused, suicidal, and agitated, medical information filed in U.S. District Court docket in Billings present. When Dowd entered Canyon Creek, managers warned workers in a be aware later filed in courtroom that he could possibly be “bodily/verbally abusive when pissed off.”
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 accordance with a witness assertion filed in courtroom. 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 laborious that when he hit the ground, his cranium fractured and mind hemorrhaged, in accordance with 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 practically three extra years, throughout which period he repeatedly clashed with residents, typically hitting male residents and groping feminine ones, in accordance with facility information filed within the courtroom case. His anger would flare rapidly. “I am actually scared to dying of Jeff,” one nurse wrote in a filed assertion describing Dowd’s dispute with one other resident.
In courtroom, 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 that they had no firsthand information. “We had been very happy with the care Jeffrey acquired 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 frequent. Throughout the nation, residents in nursing houses 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 research in JAMA Community Open of 14 New York assisted dwelling houses discovered that, inside one month, 15% of residents skilled verbal, bodily, or sexual resident-on-resident aggression. One other research discovered practically 8% of assisted dwelling residents engaged in bodily aggression or abuse towards residents or employees members inside one month. Dementia residents are particularly prone to be concerned in altercations as a result of the illness damages the components of the mind affecting reminiscence, language, reasoning, and social conduct.
Greater than 900,000 folks with Alzheimer’s or different varieties of dementia reside in nursing houses and assisted dwelling facilities. Most of the most critically impaired dwell within the roughly 5,000 amenities with locked dementia flooring or wings or the three,300 houses devoted solely to reminiscence care. These locations are largely for-profit and infrequently cost hundreds of {dollars} further a month, promising experience within the illness and a protected setting.
Clashes could be spontaneous and too unpredictable to stop. However the probability of an altercation will increase when reminiscence care houses admit and retain residents they can not handle, in accordance with a KFF Well being Information examination of inspection and courtroom information and interviews with researchers. Properties which have too few staffers or nonexistent or perfunctory coaching for workers have a tougher time heading off resident conflicts. Properties additionally could fail to correctly assess incoming residents or could maintain them regardless of demonstrated threats to others.
“As a lot as long-term care suppliers typically do their greatest to supply competent, high-quality care, there’s a actual downside with endemic violence,” mentioned Karl Pillemer, a gerontologist at Cornell College and lead writer of the JAMA research.
“There must be rather 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 manner we now have violence-free zones within the colleges.”
A hazard to others
The primary indicators of Shively’s vascular dementia emerged in 2011 as confusion, however the illness accelerated in 2016, in accordance with interviews together with his spouse and youngsters and his medical information. He started referring to mountains he knew nicely by the unsuitable title and forgot the way to tie flies on his fishing line. “The decline was so sluggish at first we thought we might handle,” his spouse, Tana Shively, mentioned in an interview earlier than her dying this 12 months.
Because the illness progressed, his outbursts grew to become laborious to deal with. He took a swing at considered one of his sons when upset concerning the temperature in the home. He refused to swallow his drugs and fell repeatedly.
“He would begin strolling the neighborhood and get misplaced,” Casey mentioned. “He would activate the gasoline range however not gentle 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 acquired to the purpose the place we could not do that anymore.”
Dowd, in the meantime, had lived in a Santa Fe nursing house and had a protracted historical past of dementia with behavioral points, main depressive dysfunction with psychotic options, and hypertension, in accordance with medical information filed in courtroom. Dowd entered Canyon Creek in October 2018 to be nearer to his brother, who lived close by in Wyoming, in accordance with an admission discover the power offered to workers that was included within the courtroom 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 Stage C assisted dwelling facility, which allows it to accommodate folks with cognitive impairments so extreme that they can not categorical their wants or make fundamental care selections. 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, provided that regulation, Canyon Creek by no means ought to have accepted or saved Dowd. The Shively household’s lawyer, Torger Oaas, famous in courtroom papers that Canyon Creek’s consumption evaluation kind for Dowd categorized his conduct as “bodily and/or verbally abusive/aggressive 1x per 30 days.” Oaas additionally wrote in courtroom 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 premise 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 courtroom.
“He acquired into my face,” the nurse wrote. “It appeared like he was going to hit me — he had his hand/fist raised.”
‘As dangerous as I’ve ever seen it’
Folks with dementia will lash out as a result of they now not have social inhibitions or as a result of it is the one manner they will categorical ache, discomfort, worry, disagreement, or anxiousness. Some frequent triggers — overstimulation from loud noises, a frenzied environment, unfamiliar faces — are hallmarks of dementia care establishments.
“We will not count on somebody who is consistently and unfailingly disoriented to adapt to our surroundings anymore,” mentioned Tracy Wharton, a licensed scientific social employee and dementia researcher in Florida. “We’ve 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 persons are aggressive, and a few are violent,” Caspi mentioned, “however for those who look carefully, the overwhelming majority are doing their greatest whereas dwelling with a severe mind illness.”
Holly Harmon, a senior vp 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’ greatest efforts. “In the event that they do happen,” she mentioned, “suppliers reply promptly with interventions to guard the residents and employees and forestall future occurrences.”
However Richard Mollot, govt director of the Lengthy Time period Care Group Coalition, a resident advocacy group, mentioned many operators of assisted dwelling facilities, together with reminiscence care models, are pushed by the underside line. “The difficulty that we see very often is that assisted dwelling retains folks they need to not,” Mollot mentioned. “They do not have the staffing or the competency or the construction to supply protected care.” Conversely, he mentioned, when amenities have sufficient rooms stuffed with paying clients, they’re extra prone 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 Constructive Method to Care, an organization that trains dementia caregivers, famous that the house inside many amenities, with double rooms, tight frequent areas, and restricted outside entry, can gasoline 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 is as dangerous as I’ve ever seen it,” she mentioned.
‘Quite common suits of rage’
The next account of Dowd’s time at Canyon Creek relies on 44 pages of nurse’s notes, witness statements, and inner resident-on-resident altercation studies; all had been contained within the facility’s information and filed as reveals within the courtroom case. After Shively’s dying in December 2018, Dowd was given new prescriptions, though the courtroom file is unclear if the change was due to Shively’s dying. Nonetheless, the information present, Canyon Creek was unable to move 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 accordance with 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. In keeping with a witness assertion, as a nurse took the resident to the lavatory, Dowd muttered below his breath: “Stuff his head in the bathroom.”
Different conflicts had been bodily. Dowd shoved a resident “down on his again so laborious his head bounced off the ground,” a nurse recorded in a be aware. In a distinct 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 accordance with two resident altercation studies.
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 fairly than pee on the ground, leading to a battle. 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 might do to defuse the state of affairs. I am actually scared to dying of Jeff. I am scared to strategy him and speak to him when he will get into these quite common suits of rage.”
Dowd in the end 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 preventing 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 and marketing director, mentioned in his e-mail that the employees at Canyon Creek and different Koelsch amenities are “extremely certified” and “extensively educated.” He mentioned the corporate’s reminiscence care communities are “distinctively designed and staffed” for folks with Alzheimer’s and different types of dementia.
‘It is good to have a girlfriend’
The nursing notes and statements within the courtroom 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 would not be higher off if he wasn’t round anymore.”
Nurses famous Dowd repeatedly exhibited sexual conduct that was both inappropriate — making “crude oral gestures whereas taking a look at youthful females” — or ambiguous, equivalent to inserting his hand on a resident’s shoulder and commenting, “It is good to have a girlfriend.” Somebody noticed Dowd “grabbing on a number of residents[‘] non-public areas,” a witness assertion mentioned. When nurses caught the conduct, they separated these concerned and rebuked Dowd. A employees member wrote in a press release that Dowd was inappropriate all through her shift, making sexual jokes and “attempting to seize me.”
In keeping with nursing notes, in summer season 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 below her shirt and pants. The caregiver advised Dowd to “cease it and never ever do this once more” and introduced the girl out to fulfill 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 accordance with a nurse administrator’s testimony in a deposition filed in courtroom. The nurse testified Dowd was now 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 Providers, which oversees the hospital, wouldn’t affirm 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 courtroom submitting, Shively’s lawyer requested permission to share proof with the jury that Canyon Creek gave its govt director a bonus any month when 90% or extra of the beds had been crammed so he might argue Canyon Creek had a monetary motivation to confess Dowd. However the decide additionally barred that data from the trial, which Canyon Creek mentioned in a courtroom 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 triggered 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 do not understand it actually modified something. For me, I acquired some closure. I really feel like these amenities are simply persevering with to do the identical issues they are going to do as a result of there hasn’t been systemic change.”
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