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Mental Health, Story One: Deadly Neglect

By Kelley Weiss


Kansas City, MO –


About 3,000 of Missouri's poor and mentally ill live in residential care facilities, or group homes. Records show state inspectors cite these facilities repeatedly for medication errors, money mismanagement, lack of staff and sometimes even preventable deaths. In one 2004 case, a woman collapsed in a group home near Kansas City and died after trained employees stood by without giving her first aid. A three-month-long KCUR investigation found that in the last three years, the state fined other facilities for the deaths of at least four more people who died in group homes statewide. KCUR's Kelley Weiss has the first of three stories in a two part series.

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After Diane Sue Class's husband died she became severely depressed and started abusing drugs. She then was admitted to the Superior Park Assisted Living group home in Excelsior Springs in 1998. Her family thought the facility would take care of Class, an attractive 62-year-old woman who liked to do her hair and wear jewelry. She needed antidepressant medications. And, as an addict she needed to be away from drugs. But Patsy Class, Class's sister-in-law, says the facility failed her.

Patsy Class: "They should have seen long before they found her on the floor dead that she was in trouble. From the sounds of this they had plenty of time to get her to a hospital and get her some treatment. She should not have died."

A statement of deficiencies report from the Missouri Department of Health and Senior Services shows on February 8, 2004 Class fell out of bed several times in the middle of the night and an employee found empty packets for 92 ephedrine tablets in her room but did not report it until hours later when police arrived. The report goes on to say that witnesses who saw her that night say she was shaking, couldn't walk straight and looked pale. When she collapsed in the hall and called for help three trained employees came to her side, one called 911, but they did not administer CPR. One employee expressed concern to state inspectors about coming in contact with Class without a CPR mask because of her rumored promiscuity. According to the state report, the employee told investigators, "It was better to be safe than sorry. Why put two people down?"

When police got there they found Class dead and alone in her room with fecal matter spread across the floor, the bed and all over her body.

Class's physician, Dr. Howard Pickett, points out the chance of saving her life when she collapsed in cardiac arrest was slim. He worries that she had access to the drugs in the first place, a problem he often sees when visiting other group homes.

Dr. Howard Pickett: "If she had been able to be kept without using drugs, if she had been kept clean, she had a good chance of survival - I mean the average woman lives to be about 80 - so she had at least 20 years of probably some average health."

Anthony Smith: "The fact that she passed away at such an early age, is an absolute tragedy, I think, more than any thing else. It really saddens me."

That's Anthony Smith, Class's only child. Smith says he didn't learn the truth about how his mother died until KCUR contacted him and shared state and police records. In fact, he says he didn't even know that she had died until he made a routine call that February morning to Superior Park to talk with his mom.

Anthony Smith: "The nurse had told me that my mother had passed away during the night. It was obviously a shock. As far as the circumstances surrounding her death, they gave me no information at all."

Superior Park's administrator, Tom Walker, would not talk with KCUR on his attorney's advice. A letter from the Missouri Attorney General's Office shows the state fined Superior Park $300,000 for Class's death. Relatives say they did not know about the fine either.

But, Class's family says it wasn't just the facility that failed her. They say her guardian failed her too. The court appointed Clay County Public Administrator Beverly Sue Ryan to be Class's guardian in 1998 and the family alleges Ryan did not do her job of managing her $75,000 estate. Class's brother-in-law, Don Class, says when Ryan became her guardian she stopped billing the health insurance Class had through her late husband's job at Ford Motor Company. The office of Class's physician, Dr. Pickett, confirmed she had private health insurance and Medicare until she died. After the county took over, court records show Class's medication costs jumped from $70 per month to about $700 per month and when she died records confirm her estate had been depleted from $75,000 to $19,000.

By direction of the Clay County Attorney, Beverly Sue Ryan and the current Clay County Public Administrator, Debbie Gwin, declined repeated requests for an interview saying they cannot comment on individual cases.

One person who would talk about this case was the director of the Missouri Department of Mental Health, Keith Schafer.

Keith Schafer: "So, it's a combination of adequacy of staff, adequate training of staff and reinforcing the policies that are understood."

Even though he says both the Department of Mental Health and the Department of Health and Senior Services license Superior Park he admits there were many problems at the facility. Glancing at the details of the death report, Schafer calls it classic and an example of failed quality controls.

Keith Schafer: "I can't speak on behalf of the residential care community but I would bet you that they will tell you we barely have the money to keep staff on board and to buy the meals and do the med management. We do not have the luxury of a good quality review system."

Frank Murphy used to work as the Jackson County Public Administrator and now is an attorney representing the mentally ill. Looking over the state reports made Murphy sad.

Frank Murphy: "I was thinking that it was disappointing. I was thinking that it was tragic. And, I was thinking that it probably happens too frequently."

Murphy was right. In the last three-and-a-half years, the Missouri Department of Health and Senior Services fined other group homes for at least four more resident deaths state wide, a rape, and in one case, against management for severe mental and verbal abuse of residents. One DHSS official called these deaths and incidents preventable. Beyond Class's death, these residents died by suicide, medication errors and lack of emergency first aid.

Funding for health care coverage on KCUR has been provided by the Health Care Foundation of Greater Kansas City.

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