James “Milt” Ferguson, a 91-year-old World War II Navy veteran, died mysteriously in a Veterans Affairs nursing home after his wheelchair spontaneously tipped backward and threw him on the floor smashing his head.
Last year in December 2018, he was entrusted to the professional care of VA Nursing Home in Des Moines, Iowa—at least that’s what his son, Jim Ferguson Jr., was led to believe. Before that time, Ferguson Jr. had been taking care of his father for three years by himself, USA Today reported.
Ferguson Jr. wanted answers but got only more puzzled—and increasingly frustrated—after seeing the institution’s video footage, dated Dec. 20. The video shows his father rolling in and out different chambers of the VA facility. James, who suffered from dementia and was legally blind, appeared to be severely distressed. No staff members are visible. He then rolls into one of the rooms, almost completely disappearing from the camera’s sight, but then, abruptly, he is tossed backward and lands on his head. Jim Jr. says he heard word that another resident of the facility pushed his father back out.
Surveillance video captured the deadly blow to the head of 91-year-old James “Milt” Ferguson Sr. Specialists say it could have been prevented.
Posted by USA TODAY on Saturday, May 4, 2019
“I lost it,” said Ferguson USA Today, when he was shown the video. “I broke down.”
The blow did not seem to affect Ferguson Sr. too much, because he managed to get back in his seat, but days later he was dead—caused by a severe cerebral hemorrhage.
Ferguson is not only concerned about the way the wheelchair got toppled over—which shouldn’t have been possible because it was secured with extra wheels on the back—but also of the security protocol—or lack thereof—that followed by the caretakers of the institution after the fall that led to his ultimate—and possibly avoidable—death. He also questions how it could be possible the nursing let his father wheel around unchecked for so long.
After the incident, staff members helped Ferguson Sr. back into his seat but failed to report the incident to a supervisor for forty minutes. By that time, a golf ball-sized lump had appeared on the back of Ferguson’s head. After that, it wasn’t for two hours before the patient was brought to an emergency room and another two-and-a-half before he was transferred to a trauma hospital.
Robyn Grant, director of public policy and advocacy at The National Consumer Voice for Quality Long-Term Care, viewed Ferguson’s medical records at USA Today’s request. She concluded: “They should have had some intervention so they could provide him with adequate supervision and address the wandering.”
Grant also questions the amount of time it took afterward to adequately evaluate and diagnose the severity of his injury. And why it took so long to get him to a trauma facility. “What was happening there, in terms of those delays?” she said.
In March USA Today reported that a private contractor hired by the VA found that 52 out of 99 VA nursing homes failed to comply with safety procedures and caused an “actual harm” to its inhabitants. The Des Moines VA was listed among the worst, scoring only one star out of five, according to the organization’s own query.
A spokesman for the Des Moines VA, Timothy Hippen, however, stated: “Any time an unexpected death occurs, VA Central Iowa Health Care System reviews its policies and procedures to see if changes are warranted,” Hippen told USA Today. “We did that here, finding that all staff acted properly.” He continued: “We will not be addressing the specifics of this case publicly, but we have been in direct contact with the veteran’s family to discuss their concerns.”
Ferguson is not satisfied with this answer and still wants to hold them accountable. “No one should live their life like that and have what happened to him in the end,” Ferguson said. “I want this to be the last person this happens to.”
