MONTGOMERY COUNTY, Texas —The family of a former Texas legislator says he was abused while being treated in a local nursing home.
Donald Brown was a state representative from Galveston County in the 1960s.
As an attorney, Brown sought justice for over 33 years. In the 1980s, he was one of the lawyers who helped clear Clarence Brandley, who was wrongly convicted of rape and murder and spent nine years on death row before he was exonerated.
But Donald Brown’s daughter says what happened to her father at the end of his life was a crime and now he needs justice.
Brown died just days after leaving Willis Nursing and Rehabilitation in Montgomery County. Pictures taken of Brown after he spent two weeks at the facility shows he had horrible bed sores.
His daughter also claims he was over medicated.
"After about the first week there, he was so drugged when I or anyone else visited him, that we couldn’t wake him up," said Celia Brown.
Her father, who was 79 and in poor health, went to the Willis nursing home on August 19 to recover from hip surgery. He was rushed back to a hospital in Conroe on September 3 in respiratory distress and died three days later.
"With proper care he could have been rehabilitated and be alive, either in the nursing home or in a private care setting," said Brown.
Brown, believing her father was abused and neglected at the nursing home, filed a complaint with the Department of Aging and Disability Services, the Texas agency that inspects nursing homes. She also filed a criminal complaint with the Willis Police Department.
Accusations of neglect at nursing homes are not unusual. However, when nursing homes are investigated, the chances of anything happening to the facilities are slim.
In 2009, the Department of Aging and Disability Services investigated 16,000 complaints in the state’s 1,100 nursing homes. Out of all the investigations, the agency revoked one license and handed out 37 administrative penalties. Not one facility was suspended.
11 News also sifted through hundreds of pages of reports, detailing accusations made against Willis Nursing and Rehab. In the past five years, 45 people made more than 100 allegations of everything from neglect and abuse, to lack of care. Of those allegations, 11 News found three instances where the nursing home was cited for a violation.
"It’s actually very rare for us to take that severe an enforcement action," said Cecilia Federov, a spokesperson for the Department of Aging and Disability Services.
Federov said shutting down or closing a facility is rare because, when the agency finds problems, the nursing homes are given a chance to make improvements.
Federov said she would not agree that the nursing homes are given a lot of leeway during investigations.
"We have to keep in mind that moving a resident, forcing a resident to move into a different facility or closing a facility, so that there are fewer facilities in the state, that is very traumatic for the population we are serving," she said.
Federov said rigorous, unannounced inspections of nursing homes, like the one in Willis, are done once a year. She said the agency investigates every complaint.
11 News obtained a copy of the nursing homes skin evaluation sheet on Donald Brown. The evaluations showed he had four bed sores when he was admitted on August 19, all in the early stages. One of the sores was on his hip, two were near his tail bone, and another one was on his right heel.
That day the nurse indicated his heel was a stage-one bed sore, meaning the skin was intact.
But a picture of Brown’s heel the day he left the facility two weeks later showed the skin was gone. The pictures of Brown’s sores near his tail bone were equally as gruesome.
When shown the pictures by 11 News, Federov agreed they were disturbing.
"You know this is horrible, this wound is horrible, we would not say this is not a very tragic condition," she said.
Two weeks after 11 News’ interview with Federov, the state completed its investigation of Donald Brown’s case. The agency found that Willis Rehabilitation and Nursing had not broken any rules. The charge of over medicating was found to be unsubstantiated, as were the charges of neglect and failure to prevent bed sores.
A nurse said in the report that Brown’s right heel, the one that lost all the skin, "went bad very quickly." She also said Brown refused to turn and would rub his heel on the bed.
Brown’s daughter, Celia, was upset with the findings of the investigation.
"Wow, they are really under qualified to investigate, or choose not to see the truth in front of them," she wrote in an email to 11 News.
Valerie Chartier, an administrator of Willing Nursing and Rehabilitation, said she thinks the report spoke for itself.
"We remain committed to providing the finest care for our patients," she said in a written statement.
But when that care falls short, is the state doing enough to protect people’s loved ones? Celia Brown doesn’t think so. Her father once served the state of Texas. In return, she believes the state failed him.