State probes nursing home after woman's death
by Jules Crittenden, Boston Herald, Friday, March 9, 2001

A Fairhaven nursing home cited just weeks ago for failing to keep track of patients is under investigation after an 85-year-old woman with dementia wandered off before dawn in her nightgown and died on a snowy riverbank.

Just how Martha Izidoro of New Bedford slipped out of the Nichols House Nursing Home—which is required to have door alarms—is unclear, state officials said.

She was last seen during a head check by the night staff at 3:30 a.m. Wednesday, the home told the Department of Public Health.

Staffers told DPH investigators they noticed Izidoro was missing about 4 a.m. and began searching the grounds.

The woman was found in her nightgown, clutching a bag of birdseed, on a rocky area on the banks of the Acushnet River, about 100 yards from the nursing home at 5:15 a.m., DPH spokeswoman Roseanne Pawelec said.

Fairhaven police said they were called 23 minutes later.

"The staff believes she had slipped, fallen and possibly hit her head," Pawelec said.

An autopsy was planned to determine the cause of death and the case is being investigated by police as well as DPH officials, who slapped the home in an 84-page report only weeks ago.

The nursing home faces stiff fines, possible closure or an admissions freeze if the woman's death is linked to poor staff procedures or other preventable inadequacies.

"We're looking for what possible explanation there could be for a patient wandering through alarmed doors," Pawelec said.

She said the facility is supposed to have doors that sound an alarm when opened. Pawelec was unable to say how or why Izidoro obtained the birdseed.

The 106-bed Nichols House - owned by the Kentucky-based Vencor chain of nursing homes - has been under DPH scrutiny since an annual DPH review on Feb. 5 found 84 pages of problems mainly related to poor supervision of patients.

The DPH issued a finding of "substandard care" - one step above the most serious "imminent jeopardy" listing that can lead to a shutdown.

Ironically, the home's management responded yesterday to a Feb. 21 DPH demand that it address the myriad problems.

While the Nichols House has no history of problems before last month's inspection, Vencor has faced serious enforcement actions at three other Massachusetts nursing homes.

The state issued "imminent jeopardy" citations at the Hammersmith nursing home in Saugus and the Star of David facility in West Roxbury last year over supervision, staffing and other issues, according to DPH records.

Vencor's Country Manor home in Newburyport was placed on the imminent jeopardy list last month, but details of problems there were not available late yesterday. Vencor owns 35 nursing homes in Massachusetts.

Nichols House management did not respond to a request for an interview, but issued a prepared statement that said:

"The care and safety of our residents is always our number one concern. This is a sad and unfortunate situation and our thoughts and sympathies go out to the family and friends of Mrs. Izidoro. Upon learning of the incident the facility followed the proper procedures and notified the proper local authorities. We are currently conducting an internal investigation and based on patient confidentiality cannot comment further."

Izidoro was married for 58 years to Joseph Izidoro, 82, of New Bedford. Efforts to reach Izidoro's family were unsuccessful yesterday.

Pawelec was unable to confirm that Izidoro suffered from Alzheimer's disease, saying DPH only knew that she had some form of dementia but did not have a history of wandering in more than two years at the nursing home.