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State AG takes up case of disabled Spokane woman who died in care

UPDATED: Tue., Dec. 17, 2019

Washington state Attorney General Bob Ferguson speaks at a news conference in Seattle in this Dec. 12, 2019 photo. Ferguson’s office in August launched an investigation of a Spokane supported-living company whose employee is accused of giving a patient a lethal dose of cleaning vinegar rather than medication in February. (Elaine Thompson / AP)
Washington state Attorney General Bob Ferguson speaks at a news conference in Seattle in this Dec. 12, 2019 photo. Ferguson’s office in August launched an investigation of a Spokane supported-living company whose employee is accused of giving a patient a lethal dose of cleaning vinegar rather than medication in February. (Elaine Thompson / AP)

The Spokane Police Department determined it couldn’t pursue charges in the case of a developmentally disabled woman who died earlier this year after a caretaker gave her a lethal dose of vinegar instead of her medication, so the department instead referred the case to the state attorney general’s office for further investigation.

In court filings last week, the attorney general’s office investigator laid out how it says a caretaker acted negligently, committing second-degree manslaughter and third-degree assault as well as first-degree theft by receiving payment through Medicaid funding for improper medical care.

The caretaker has not been charged with a crime, but the decision to pursue the charges came after an investigation that began in mid-August, three days after the Washington Department of Social and Health Services terminated its contract with Aacres, a state-subsidized, supported-living service for adults with developmental disabilities in Spokane.

Marion K. Wilson, 64, had been receiving care at an Aacres facility for at least two years before she died Feb. 27.

Aacres caretakers said Wilson was wheelchair-bound and had the mental capacity of a 5-year-old, according to a search warrant filed by a state attorney general’s office investigator.

She died from ingesting cleaning vinegar instead of bowel preparation solution, according to the Spokane County Medical Examiner and investigative reports. In a matter of hours after ingesting the vinegar, Wilson suffered irreversible tissue death and inflammation of the esophagus, stomach and small bowel, eventually killing her.

The facility’s staff did not immediately report that negligence may have been a factor in her death to state regulators, despite requirements to do so, according to investigative reports. By the time the Spokane Police Department was notified, there was no crime scene to investigate. The Spokane County Medical Examiner later ruled the death an accident.

The day before Wilson died, the house manager for the Aacres facility gave two night-shift caretakers directions for how to give Wilson a preparatory solution for a bowel examination, court documents say.

One caretaker, who has not been charged with a crime, was in charge of administering the medication. The other, a primary night-shift caretaker whom the attorney general’s office is investigating, asked many questions but believed she understood the instructions, according to the house manager.

Despite that apparent understanding, the primary caretaker pointed to jello in the fridge and asked if it was the bowel preparation solution, according to a Department of Social and Health Services investigation.

The primary caretaker later admitted she did not read the directions for the medication written on a whiteboard.

Another employee told investigators she watched the primary caretaker give Wilson half of the solution a few hours after they received instructions from a supervisor, court documents say. The rest of the medication was put in a refrigerator until it was supposed to be given to Wilson later that night.

Earlier in the day, a day-shift caretaker placed a gallon bottle of cleaning vinegar near a coffee pot in the kitchen of the facility, which was a three-bedroom home that housed two clients, according to court documents. The day-shift caretaker bought the vinegar and cleaned the coffee pot, then showed the night staff where the bottle was.

A night-shift employee told investigators she woke Wilson up around 3 a.m. to use the bathroom, according to court documents and investigative reports.

While she cleaned the bathroom, the primary caretaker gave Wilson what she thought was the remaining medication. The primary caretaker later said she didn’t check the label first.

Wilson drank three to four cups, but not as fast as she had previously, the employee said in court documents. She said she was cleaning with bleach and did not notice any vinegar smell.

When a morning-shift caregiver arrived at the facility the next morning around 6 a.m., she noticed Wilson’s medication bottle was still in the fridge and half-full, according to court documents and investigative reports. She called an Aacres supervisor around 7 a.m., but the night caretaker now being investigated insisted the medication had been administered.

While the day-shift caretakers were preparing to take Wilson to the hospital, one said she would use the empty bottle of cleaning vinegar by the recycling bins outside to spread de-icer on the sidewalk, court documents say. She then remembered how she had only used about half the vinegar to clean the coffee pot.

Staff members reported they had Wilson smell the empty vinegar jug, and she said it smelled like what she drank earlier that morning, according to investigative reports.

An employee said she tried to call Wilson’s doctor at Providence Holy Family Hospital to say Wilson did not finish the solution but could not get through, according to court documents and investigative reports.

Aacres employees brought Wilson to the hospital around 8 a.m., and they told a nurse she may have drank vinegar instead of the solution around 9:15 a.m.

The doctor, through a nurse, told the caretaker Wilson would be fine, court documents say. Wilson then began slurring her words and wheezing and told the caretaker, “This is a really (expletive) day.”

Hospital staff checked Wilson’s pulse and her lungs when they were notified and immediately took her to the emergency room, court documents and investigative reports say.

Wilson was turning blue as she was brought to the emergency room, according to investigatory reports. She arrived at the department unresponsive and was pronounced dead just before 10:15 a.m.

Medical staff were limited in what life-saving measures they could provide to Wilson because of a legal order not to resuscitate her.

But Aacres staff did not indicate to state regulators that neglect may have been a factor in the death until March 1, according to DSHS.

DSHS began an investigation March 12, and in that time Aacres began an internal investigation. But in early April, Aacres’ executive director did not provide interviews with staff in a copy of their investigation and did not hand over written statements from involved employees until July.

Aacres fired the caretaker who reportedly gave Wilson the vinegar on April 19. The other night-shift employee received a final warning for violations of a medication administration policy after that, according to investigative reports. The caretaker who was fired and is now being investigated by the attorney general’s office does not have a criminal record in Spokane County, according to court records.

An attorney general’s office investigator found Medicaid was billed more than $12,000 for Wilson’s emergency room care, plus the cost of her care at Aacres, according to court documents.

“Medicaid paid for both the wrongful acts that lead to (Wilson) requiring hospitalization as well as the hospitalization resulting from the lack of care,” an investigator wrote in court documents. The caretaker who gave Wilson vinegar rather than her medication “should not have received Medicaid money as payment for services when she did not provide the services required.”

The attorney general’s Medicaid fraud division engages in both criminal and civil investigation and prosecution of healthcare-provider fraud committed against the Washigton’s Medicaid program, according to its website. The division also monitors complaints of resident abuse or neglect in Medicaid-funded facilities and assists local law enforcement in investigating and prosecuting crimes committed against vulnerable adults.

The attorney general’s office declined to comment on Wilson’s death due to the active investigation.

The attorney general’s office can prosecute Medicaid fraud through the civil justice system, but the governor, local law enforcement or local prosecutors must request its involvement in criminal investigations and prosecutions.

The Medicaid fraud control division prosecuted or referred to prosecutors five criminal cases and 16 civil cases in 2017, according to a division annual report. The division investigated another 70 cases that did not have enough evidence for prosecution.

Criminal restitution for four of the criminal cases ranged from $2,000 to $33,000, but none involved a client death, according to a report. Restitution related to Washington state civil cases ranged from $73,000 to $400,000.

The attorney general’s office has not contacted the Spokane County Prosecutor’s Office, according to Prosecuting Attorney Larry Haskell.

The Spokane Police Department did not investigate Wilson’s death after the county medical examiner determined it was an accident, according to Sgt. Terry Preuninger, a police spokesman. The department became aware of the death through a Crime Check report some time after Wilson’s death, Preuninger said, and an investigative sergeant reviewed it. At that point there was no crime scene for evidence collection. The police sergeant referred the case to the attorney general’s Medicaid fraud division, which he believed to be the more appropriate investigate agency, Preuninger said.

“If SPD were to become aware of information that could change the dynamic here, I am sure they would act on that, conduct an investigation and forward me a referral,” Haskell said.

Aacres is the sister company of S.L. Start & Associates, another in-home care provider for people with developmental disabilities, that DSHS revoked licensing from a year before. DSHS placed many of that provider’s clients with Aacres Washington, even though both providers are owned by the same company, Spokane-based Embassy Management.

Embassy Management said it is cooperating fully with the investigation of Wilson’s death in a statement.

“At Aacres Washington and Embassy Management, we take the health and safety of our clients extremely seriously and were devastated by the death of this individual. We are committed to providing the highest level of care at our supported living homes and are working continually to ensure that each of our homes and care professionals is equipped to provide that care to our clients,” the statement said.

Aside from the death of Marion Wilson in February, DSHS investigations determined Aacres staff in Spokane, including a supervisor, failed to report incidents of “isolation and mental abuse” of three clients. Aacres staff also failed to ensure that one client took mental health medication for six days and failed to notify the doctor who prescribed that medication.

Aacres provided services to nearly 60 adults in the Spokane area, and its contract was worth more than $700,000 a month. DSHS halted placement of clients at Aacres facilities in July. DSHS terminated Aacres’ contract in August and revoked its three Spokane facilities’ certifications at the end of October.

This story has been updated.

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