New reports reveal state ambulance investigations
There is new information detailing the failures of a nursing home and ambulance company that refused to call 911 for a cardiac arrest patient, left waiting for help.
Eyewitness News Investigator Sandra Chapman first uncovered the disturbing response that put business before patient care. Now, there are disturbing details of two state agency investigations and a call for change.
Rick Parcel of Greenwood can't believe health professionals failed to do something so basic.
"It's just a simple 911 call," he said.
Three digits that could have saved his mother Barbara's life, when she went into cardiac arrest March 5.
A team of state health inspectors investigated and now say it's true, Wildwood Healthcare "failed to ensure appropriate care," by failing to call 911.
The investigation behind closed doors at the Wildwood Nursing Home came mere days after medics broke their silence to 13 Investigates.
"People should be shocked by it," admitted one medic.
"They will do everything in their power to not turn the run, in order to be able to bill that run for themselves," added a another medic. The medics' identities are being withheld out of fear of industry retaliation.
The medics confirmed to 13 Investigates a secret practice of some nursing homes and private ambulance companies keeping ambulance runs at all costs, with little consideration for patients' lives.
Now, the disturbing details and troubling violations have gotten the attention of State Senator Pat Miller, who is a registered nurse. Miller chairs the Health and Service Providers Committee.
"One incident like this is one incident too many in the state of Indiana," she told 13 Investigates during an interview in the Senate chambers at the Statehouse.
In a 10-page report obtained by 13 Investigates, health inspectors say the LPN who cared for "Resident A," Barbara Parcel, had two chances to call 911. Instead, the LPN chose CARE, the nursing home's contracted private ambulance company.
Parcel's best friend first alerted staff that Parcel was having trouble breathing at 7:45 p.m. on March 5.
"She should have had help right now, as quickly as she could," Elsie Britton told 13 Investigates.
But investigators learned the LPN continued handing out medications to other residents, before responding and finding Parcel "unresponsive." The LPN told investigators, she "left the room" called "emergency transport" but said it was "not necessarily a life threatening ordeal."
"She did not call 911," even though IFD Station 43, the closest emergency crew was just around the corner.
"It should, it should make us angry," said Britton.
Just as troubling, the LPN says she "did some paperwork," then decided "I better go back and check on her."
Parcel was not breathing. Once again, the LPN left the room to get a "crash cart," but did not call 911.
"That seems just ludicrous!" said Rick Parcel.
He told 13 Investigates it never occurred to him to ask Wildwood Staff who they routinely called for emergencies. He thought it was a given.
"You ask what you think are legitimate questions. But I never thought to ask if someone goes into cardiac arrest. Do you call 911?," he said in disbelief.
Now, for the first time, Wildwood and the LPN are being forced to answer for their actions.
CARE Ambulance had serious problems too.
The private company had just one Advanced Life Support crew available that night. It was 18 minutes out of town, near Avon.
In its investigation, the State EMS Commission determined the following timeline:
8:08 p.m. - The call regarding an "Unresponsive Patient" from Wildwood.
8:14 p.m. - The Avon unit was dispatched. The paramedic on board warned he was too far away and told the dispatcher to call 911 instead.
8:16 p.m. - CARE scrambled a crew from its headquarters west of downtown.
8:29 p.m. - That unit finally arrived.
It took CARE Ambulance 21 minutes to get help to Barbara Parcel, only to discover another problem. The LPN told investigators the crew was not equipped to handle a cardiac arrest. The fire department had to be called anyway.
13 Investigates demanded answers from CARE.
"Taking 20 minutes to get to a patient in cardiac arrest when there was a fire department five minutes away, that that was the best response?" asked 13 Investigates.
"Well, our response time wasn't 20 minutes," denied a company spokesman, who spoke in the company's lobby.
Now, six months later, we go back armed with new internal memos obtained by 13 Investigates, detailing critical missteps. But we're told no one is available to speak with us, despite the many phone messages we left for comment.
The company's former spokesman had previously admitted problems.
"We have been able to identify some flaws on our part that we are implementing and addressing some strategies to be able to move forward. So that these types of things don't happen," he said months ago.
Reports show there were problems with the truck CARE scrambled from headquarters. In a memo, the dispatcher working that night said, "There was no cot in the back of (the) truck" and that caused delays. That same dispatcher says she called the unit near Avon, because of "not being able to turn runs." In other words, she was not allowed to send the call over to the city's 911 emergency system to handle.
That means, for the first time in writing, a CARE employee admits to a policy that forbids calling 911.
"Somebody made a conscious decision, made a policy decision," said Rick Parcel added.
"I was not aware and I'm surprised that there is a policy," said Senator Miller.
But according to the state's EMS Director Rick Archer, someone was mistaken.
"According to the reports that we received from CARE, the interpretation of the dispatcher of that was wrong," he told 13 Investigates.
Archer is also a member of the EMS Commission, the very agency that investigated CARE. Turns out neither he nor the commission saw another memo dated May 15 from a CARE supervisor.
That memo says "A 'no rollover' policy had been implemented and had been rescinded around the time this run occurred. It appears the dispatcher was unaware of this policy change."
When confronted with the document, Archer revealed that Indiana law is silent on the issue.
"Unfortunately, there's not a rule that says the agency is required to turn over calls to 911," he said.
Then there's a company-wide memo issued just two weeks after Parcel's death, in which CARE changed its Emergent Response policy, citing an internal audit and its Medical Director, Dr. Ed Bartkus of IU Health.
It says "If a response will take greater than eight minutes, then we need to have the local EMS/Fire Department dispatched."
Despite all that, Indiana's EMS Commission determined CARE did nothing wrong. Archer acknowledged there aren't any specific rules on response times or turning calls over to 911 in Indiana.
But CARE is not necessarily in the clear. In an email to 13 Investigates, an agency spokesman confirmed another investigation has been launched. The EMS Commission now wants to know if the crew that responded to Wildwood had the proper equipment to handle a cardiac arrest patient.
"Is it a violation for an ambulance to show up on a call and not have the appropriate equipment?," asked 13 Investigates.
"It would be a violation if that could be substantiated. Yes," Archer responded.
Wildwood Healthcare disciplined the LPN involved. The facility itself must undergo more inspections by state health department regulators.
That's good news, according to Senator Miller.
"This facility will have to adopt policies to make sure that this doesn't happen again," she said.
Senator Miller is now asking anyone with information on nursing homes or ambulance companies refusing to call 911 to contact her. She's looking to propose possible legislation this coming session.
The parent company of CARE Ambulance told Eyewitness News Saturday night they have no comment on the latest reports.
Meanwhile, Michael Clancy, executive director of Wildwood Healthcare, issued the following statement Saturday:
"Resident care and safety is our number one concern. We take seriously any issues brought to our attention by the state. Regarding this issue, we filed a plan of correction with the state and it was approved by the state. Upon re-survey they found us to be in compliance with all state regulations. Due to regulatory constraints related to patient privacy we are not able to comment on any specifics."