The daughter of a Gillette assisted living center patient who died of an opioid overdose in late November filed a lawsuit Wednesday against the facility, the Campbell County Hospital District, a nurse, and a hiring agency.
Christina Jones’ lawsuit seeks wrongful death damages on behalf of her late mother, Rhonda Parker, 66, who died of a Tramadol overdose on Nov. 29 at The Legacy Living and Rehabilitation Centre. The lawsuit claims that her death occurred hours after she displayed severe symptoms that her caregivers ignored.
Steven Titus of Gillette-based Steven Titus & Associates filed the complaint in Campbell County District Court on Wednesday against the Campbell County Hospital District (and Legacy under its umbrella), licensed practical nurse Emily Ware, and FocusOne Solutions LLC, a Nebraska-based nursing recruitment company.
Jones’ complaint seeks over $51,000 in damages. She is requesting a jury trial, all legal compensation, including punitive damages, and reimbursement for her legal expenses.
The shutdown
Rhonda Parker died on the morning of November 29 at Legacy.
Parker had reported to a certified nursing assistant the day before, Nov. 28, at 7:30 a.m., that she might have pneumonia and was having difficulty breathing, according to a Gillette Police Department report by Officer Kyle Sprague.
The CNA informed nurse Ware, who entered the room about a half hour later to assess Parker by taking her vital signs, which were normal, according to the report.
According to the lawsuit complaint, the nurse provided Parker with a breathing treatment that included the respiratory medication Duoneb.
Parker requested to visit the emergency room, according to the report.
Ware responded that Parker was “fine,” it adds.
Parker went back to sleep for about 30 minutes after noon. When staffers woke her up, she had an incontinence incident and needed assistance getting out of bed, according to the report. She then ate a light lunch, which was unusual for her, and appeared lethargic, weak, and disoriented, Sprague reported.
Later, while Parker was using the bathroom, the CNA noticed “seizure activity,” according to the report, and Ware did not assess the situation when informed of the seizure.
According to the report, Ware called a nurse from another floor for a different opinion.
Around 2 p.m., a housekeeping staffer reported that Parker had complained of chest pains; however, Ware “once again said she was fine,” according to Sprague.
The officer added that the complaints escalated and reached the charge nurse through several staff members.
The charge nurse instructed Ware to perform a complete assessment and vitals on Parker. According to the report, Ware just took the woman’s vitals.
“Nurse Emily advised Rhonda that since she could not rate her pain, she was fine,” the officer wrote in the police report.
Parker asked if she could get back to sleep. She refused to eat dinner and slept all night, which the police report says was unusual for her.
Parker was found unresponsive at 4:20 a.m. on November 29. CPR was attempted. According to the report, emergency medical personnel arrived on scene and pronounced her dead at 5:02 a.m.
On Wednesday, Gillette Police Department Deputy Chief Brent Wasson told Cowboy State Daily that the investigation into a potential criminal case is still ongoing, and no one has been charged or arrested.
Overdose
According to the lawsuit complaint, Dr. D.M. Habbe of Pathologists of the Black Hills performed an autopsy on Parker’s body on December 4 and determined that her death was caused by Tramadol toxicity.
Parker’s Tramadol level was 7300 nanograms per milliliter of blood, or “more than seven times the upper limit of typical therapeutic levels – which are generally kept below 1,000 (nanograms),” according to Titus.
Parker’s autopsy report also revealed a coronary artery condition and early bronchopneumonia.
According to Campbell County Coroner Paul Wallem, Parker died as a result of a Tramadol overdose or toxicity.
Wallem listed the manner of death as undetermined, which can include natural, suicide, accident, homicide, or undetermined causes.
Standards of Care
Jones’ lawsuit accuses Legacy and Ware of “egregiously” deviating from the standard of care that should have been followed in this case.
According to the complaint, Ware failed to notify Parker’s doctor and the responsible party of her “acute change in condition” on the morning of November 28, after midday and at 2 p.m. It claims Ware should not have given Parker the Duoneb without a doctor’s order, and that he failed to call 911 and ensure Parker received proper care.
According to the complaint, Legacy failed to “immediately report neglect” of Parker to the Wyoming Department of Health following the incident, as required by federal rules.
According to the complaint, FocusOne supplied Ware to the facility, and Jones accuses FocusOne of failing to properly vet, supervise, and train Ware.
On Wednesday, FocusOne declined to comment.
Ware could not be reached by the time of publication.
Nursing Home Statement
Legacy issued a statement Wednesday stating that it is “aware” of inquiries into the case but cannot comment on specific legal claims due to “active and ongoing” elements of the incident.
“The Legacy is fully cooperating with the appropriate authorities and regulatory agencies and remains committed to transparency, accountability, and the safety of our residents and staff throughout this process,” according to a statement.
The Campbell County Health Board of Trustees addressed both this incident and another in January, when a memory care patient died outside in freezing temperatures, according to the statement.
According to the statement, district leaders fired people, reported incidents to authorities, and took other actions to address what happened.
“The meeting included a detailed overview of the actions taken to investigate and respond to each event (including) the immediate reporting of both incidents to state authorities and law enforcement, the termination of involved employees and contract personnel, the submission of findings to the appropriate licensing agencies, and the implementation of enhanced safety protocols and administrative oversight measures,” according to the article.
Regarding the November incident involving Parker, “The Legacy took swift and appropriate action,” according to the statement, adding that facility leaders reported the incident, fired the “involved” contract employee, and reported the person’s license to the state for review.
The statement does not mention Ware by name.
“We understand the public’s interest in these matters and are committed to sharing verified information as it becomes appropriate,” according to the statement. “Our primary focus remains the wellbeing and care of the residents we serve every day.”
This Case Is Not That Case
According to court documents in a separate case, an 88-year-old memory care patient died after wandering outside the Legacy building in early January.
Bernard Hale, 57, was charged with the patient’s freezing death.
Judith Duvall was discovered unresponsive on the snow on January 10 after spending more than nine hours in frigid temperatures.
