No charges filed in Clement Manor death
Posted by PKSD Law Firm on Sep 02, 2010 in Nursing Homes and Elder Rights
Officials unable to prove who acknowledged injured womans alarm
By Tom Tolan of the Journal Sentinel
Sept. 1, 2010
No charges were filed in a death last February in a Clement Manor independent living apartment because it couldnt be proved who had acknowledged an alarm from the apartment, an assistant district attorney says.
Assistant District Attorney Denis Stingl provided information Wednesday that shed new light on the Feb. 15 death of Sylvia Ploszay.
A lawsuit was filed Monday in the death of Ploszay, 87, who experienced a cut on a varicose vein near her ankle, pulled an emergency cord requesting help, and then bled to death over the four hours it took staff members to respond to the call.
According to the lawsuit and an extensive Greenfield police report on the death, Ploszay pulled an alarm cord in her room at 12:25 a.m. on the 15th, and a nurse didn't respond to the alarm until 4:20 a.m. or after. The alarm was acknowledged at a nursing station within a minute, the documents say, but not acted upon until later.
None of the Clement Manor staff members who were interviewed by police remembered acknowledging the alarm, according to the district attorneys office, although one nurse, Suzette Gorski, told police she acknowledged an alarm from the complex's loading dock between 1 and 2 a.m.
Records from the alarm system showed no such alarm, and Stingl speculates it might have been the call from Ploszay that Gorski acknowledged then. But investigators couldnt determine what was displayed on the alarm screen at that time, Stingl said.
In addition, Stingl clarified the responsibilities of a nursing assistant who was watching television when she received a call from a hallway neighbor of Ploszays reporting her alarm. Her job was to field emergency calls from the assisted living facility at Clement Manor, not the independent living building, according to Stingl, and it was her practice to watch TV while waiting for those calls. Stingl and the police report said shed told the caller to contact the complex's health office, given him a number to call and returned to watching TV. Neither she nor the caller apparently followed up.
The lawsuit complaint incorrectly identified the woman as a nurse; shes a certified nursing assistant.
Richard Rau, chief executive officer of the Clement Manor complex, wouldnt say Wednesday whether any staff member had been fired as a result of what happened, but did say, Appropriate counseling or disciplinary action was taken. Greenfield police Detective David Leon, whose investigation at the complex lasted until May, said that to the best of my knowledge, no one had been fired.
Finally, as was reported Wednesday, alarms from independent living units like Ploszays now go to a private alarm company, which informs Greenfield emergency dispatchers. In addition, though, the internal alarms at Clement Manor have been reorganized so that an alarm from a room goes off every five minutes until its reset in the residents room, according to Stingl.
Also, Stingl said, work rules have been changed so that any staff member who acknowledges an alarm or receives a call about an alarm has to immediately contact the shift supervisor.