BUFFALO, N.Y. (WIVB) — When Ruth Murray was sent to Emerald South nursing home, it was assumed the 82-year-old would live out her days in peace.
Instead, she met a violent end at the hands of another resident of the facility, a man her age with a history of aggression, who medical professionals said required 24-hour supervision.
That man, who News 4 is not naming, will likely never be charged because he’s incompetent to stand trial, according to experts.
Meanwhile, Emerald South is a nursing home with a lengthy history of repeat state and federal violations.
It generates more than 80 percent of its income from residents through Medicaid and Medicare; an approach, according to current and former employees, that focuses more on putting heads in bed than human care.
Medical records of Ruth Murray’s attacker show Emerald South knew his history from the first day he arrived.
Incidents of violence — one eerily similar to the circumstances surrounding he and Murray — in the days leading up to the beating call into question whether the staff did anything to protect other residents or themselves.
Had they, Ruth Murray’s family believes, the once-vibrant woman would still be alive.
The final goodbye
“I said, ‘I’ll see you on the weekend,” remembered Carol Kuszniaj, Murray’s daughter. “That was Thursday. That was Aug. 25. It was the last time I saw my mom.”
Carol Kuszniaj wanted to remember her mother like a picture from her 81st birthday: Surrounded by family, hair done up for a celebration, serene.
Instead, the lasting image that’s burned into her soul — but far too graphic for public consumption — is her mother clinging to life, a swollen puddle of red and blue against a white hospital pillow, frail bones twisted and broken; the results of a beating by another resident in the dementia unit at Emerald South.
“I saw her, I screamed, I fell against the wall and I went down,” Kuszniaj said through tears. “And the nurses picked me up because she was so unrecognizable. She was beaten. She was beaten to (the point) you couldn’t even recognize her.”
Police reports state Murray wandered into the wrong room, an innocent but common mistake that cost the 82-year-old her life.
News 4 is not naming Murray’s attacker because he has not been charged with a crime, though police and the Erie County District Attorney’s Office continue to investigate.
“How can something like that happen?” Kuszniaj said. “How can somebody be put into a dementia unit, Alzheimer’s unit, with that kind of aggressive behavior and not be monitored, supervised?”
The man’s medical records reveal a history of outbursts, both verbal and physical.
But they reveal even more about what Emerald South staff knew about their newest resident.
Evaluation recommends 24-hour supervision
Those records begin on Aug. 18, when Murray’s attacker was discharged from ECMC to Emerald South.
That’s thanks to Willie Faulkner, who, for the past five years, has cared for his neighbor, eventually getting him the help he required. He still sees him every week.
“I’ve been seeing him at every step, from the point he was taken out of his house because of his medical condition,” Faulkner said. “I have seen him at every step.”
Faulkner said the man would complain — at both ECMC and at Emerald South — about people coming into his room.
“He didn’t want people coming in there,” he said. “He didn’t like the noise and the people. He’s not used to that.”
But Faulkner said he couldn’t imagine his neighbor being violent toward anyone, especially a woman.
“Unbelievable. I would put my life on it that it wasn’t him,” Faulkner said. “To know him, you would love him. I can’t imagine that we would sit here and talk about something that would be so serious to him. I believe that if you mention that, he’d probably break down and cry.”
Staff at Emerald South went back to add to Murray’s attacker’s chart, writing on Aug. 30 that a psychological evaluation by ECMC determined he cannot live alone and requires 24-hour care. His initial evaluation went a step further and recommended 24-hour supervision.
Records state he “becomes confused and agitated when trying to be oriented,” and that he “has a history of delusional behaviors.”
At 6 p.m. on Aug. 23, records show the man was upset because another resident wandered into his room.
Just three hours later, this time Murray’s attacker wanders into another resident’s room.
Nursing home staff said they found Murray’s attacker “dragging the other resident out of is own bed.” Another late entry written on Aug. 30 about this incident shows he had dragged the other resident out of his bed far enough, “that his head was resting on the floor.”
After he’s removed, the staff nurse notes he returned to the wrong room still agitated, and attempted to go after the resident again.
He was “slamming the bathroom door and slamming drawers, stating that he was looking for his wheelchair,” according to records. The on-call supervisor and other nurses are made aware of the incident, and the man’s power of attorney is notified.
The morning of the fatal beating, Murray’s attacker skipped breakfast, according to records.
The entry for that day states a staff nurse found him sitting his bed, yelling, “get this man outta my room,” while another staffer attended to Murray, who was lifeless and bloody on the ground.
Records show once Murray’s attacker was informed the victim was a woman, he told the staff, “I’m sorry. I didn’t know. I’m sorry.”
The late entry for the incident written four days later — one day after Murray died from her injuries — state staff found Murray’s attacker punching and kicking her in the head.
Yet again, the staff notes the man becomes agitated as he thinks people are coming into his home.
Meanwhile, Ruth Murray lay sedated in ECMC’s intensive care unit, her family gathered around her.
Murray fought for two days before staff at ECMC told her family the injuries would be fatal. Then it was time to say goodbye.
“Tell her that she did good,” Kuszniaj said. “Tell her that it’s OK, and she said, let’s sing. … We all sang ‘Amazing Grace,’ and we told her it was OK, that we were all sorry this happened to you, this should have never happened. This wasn’t the way you were supposed to go, and we’re so sorry.”
Emerald South released a statement Friday that stated they take the confidentiality of their residents and their private medical records “very seriously.”
“It is very unfortunate that someone released the medical records of one of our residents, and possibly violated Federal law,” according to the statement. “For anyone to violate the privacy of someone who is unable to defend himself is unconscionable. We continue to fully cooperate with the investigation into this unfortunate incident.”
Living conditions Emerald South are abysmal, according to former and current employees, and families of current and former residents. A last resort.
“It’s a heartbreak any time you have to leave them in that facility,” Kuszniaj said. “I mean, if I could take her home I would.”
That’s the same experience for many who reached out to News 4 in the wake of the Aug. 26 beating, including Heide Porter, whose great aunt, as she puts it, “escaped” Emerald South just this month for a higher rated facility.
“The first thing was always the smell,” Porter said. “There was always a real strong pungent smell. It was always, it was dirty. Extremely dirty.
“I hated leaving her, and she would often, every time I’d leave she would say, ‘Don’t leave me here.’ There’s no happiness at all, I can tell you that. It’s not a happy place.”
Patient happiness isn’t a measurement conducted by state Department of Health inspectors during nine reviews at the nursing home since August of 2012.
But there are pages and pages of other ways the facility repeatedly falls below state and federal standards, leading to a one-star rating, or “much below average.”
“I feel happy that she’s gone, but I still feel bad for the people who have to live out their lives there,” Porter said.
Or in the case of Ruth Murray, die there.
“It hurts me because this could have been prevented,” she added. “This incident couldn’t have happened if somebody was doing their job, if they were supervising this man who they already knew was aggressive.
“It’s like a shock, it’s like a nightmare,” Kuszniaj said. “This wasn’t supposed to happen. Mom didn’t go to the nursing home to get beat to death.”
The Department of Health on Sept. 16 cited four deficiencies, including one at harm level because it said “the facility failed to provide adequate supervision to prevent accidents and ensure resident safety.”
The DOH said Emerald South submitted a plan to correct the fallacies on Sept. 26. That plan was rejected. The DOH said they will continue to monitor the nursing home to determine whether any stiffer enforcement action is warranted.
Emerald South declined to comment on the DOH report.