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Report: Nursing Home “Likely Caused” Alzheimer’s Patient’s Death

By Susy Solis
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Luis Martinez, 78, suffered from Alzheimer’s disease and died after wandering away from the nursing home where he lived. (Credit: Martinez Family)

FORT WORTH (CBS 11 NEWS) – A state investigation has confirmed what Victorina Rodriguez already knew in heart, that Estates Healthcare and Rehabilitation Center had been negligent with her husband’s care.

On July 8th, Fort Worth police released a Silver Alert for Luis Martinez, 78, who was last seen at Estates Healthcare and Rehabilitation Center, where he was a live-in patient. Police believed Martinez was in grave danger because he had Alzheimer’s disease and needed a cane to walk.

For 7 days, Rodriguez and Martinez’s children searched for him. Martinez’s son found the body of his decomposing father four blocks from Estates Healthcare and Rehab Center on July 15th.

Since then, Rodriguez says she has continued to ask herself what could have happened the night her husband disappeared.

One month later, CBS 11 obtained, through the Freedom of Information Act, the documents pertaining to the investigation by the Department of Aging and Disability Services, or DADS, after Martinez’s disappearance and subsequent death.

The investigation revealed that the facility did not meet state licensure requirements and put resident’s health and safety in immediate jeopardy.

Documents revealed that Martinez, who was assigned to a special ward for patients who were considered “flight risks,” was removed from that hall to make room for another patient, but employees did not assess Martinez before removing him to see if it was safe to do so.

Martinez was also left alone in a room with a door accessible to the outdoors, even though he was known flight risk, according to documents.

Family members and Martinez’s roommate has expressed concern to nursing home employees about Martinez’s desire to leave the facility saying he had called it “prison.”

Martinez was to have been fitted with a wander-guard that would beep should he leave the building. No alarm sounded the night he disappeared and a wander-guard was found in the trash the day after he disappeared.

The DADS investigation said “We found conditions in the facility that presented an immediate jeopardy to resident health and safety,” and continued, saying these failures “likely caused” the death of Luis Martinez and could affect the 39 residents, also identified as flight risks.

The investigation revealed the administrator of the hospital, Kristy Blackwell, told investigators she thought the family had taken Martinez and said the wander-guard system was “not fool-proof.” She told DADS that she thought her staff did a “fine job” the morning after Martinez disappeared.

Rodriguez plans to file a lawsuit, not for the money, she says, but in hopes of finding justice.

Since the investigation, the DADS says the nursing home has trained employees on how to deal with and identify patients who are flight risks and has implemented new strategies, including doing a nightly head count at shift change to prevent this from happening again.

Rodriguez says she is satisfied that the nursing home is making changes to protect others, but it does little to heal the pain she and their 9 year old daughter feel after losing Martinez.

Estates Healthcare and Rehabilitation Center submitted a plan of correction to DADS on August 14th. The same day DADS lifted the “immediate jeopardy” finding against the facility, which means investigators were satisfied that the facility had corrected the situation posing immediate risk to residents’ heath or safety.

The Department of Aging and Disability Services plans to make unannounced visits to make the nursing home remains in compliance with state codes.

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