‘Why’ questions permeate 2 care center deaths

There was a news update over the weekend about two elderly Iowans who wandered away from different care centers last winter and froze to death.

There is no question the deaths were horrible tragedies. There is no question they resulted from carelessness and a needless lack of attention by employees of the centers.

There are important questions that need to be asked, though. Why was one death a regrettable accident but the other death was a crime? And why, if Iowa treats the one death as a crime, is the blame not shared by others who could have stepped in and prevented the death?

The answers come down to different decisions made by the county attorneys serving the two communities, Spirit Lake and Bondurant, and to the Iowa Legislature’s decision in 2021 to classify the death of a dependent adult as second-degree murder when it results from intentional abuse or recklessness by a caretaker.

The way the cases have been handled gives rise to uncomfortable questions about whether justice is being administered fairly and equitably across Iowa.

Before we get into that, here is background about the two cases so you better understand what occurred. I tip my hat to reporter Clark Kauffman, who shined his spotlight on these cases for Iowa Capital Dispatch.

The first death was Elaine Creasey, 95, who was found frozen about 7 a.m. on Dec. 9, 2021, outside the Keelson Harbor assisted living center in Spirit Lake. Investigators determined she wandered away about 10 p.m. the night before. The door locked behind her when she left the building. There were signs she tried to get back to the door, but she succumbed in the cold, with the wind chill reaching 14 degrees overnight.

On Jan. 21, 2022, Lynne Stewart, 77, walked out of her room and then left the Courtyard Estates assisted living center in Bondurant through a side door about 9:40 p.m. She apparently fell outside, striking her head. The temperature dropped to 11 degrees below zero that night, and Stewart was found next to the door about 6:10 a.m.

In both cases, employees with responsibility for looking after the women did not follow the procedures each facility established to prevent such tragedies. But managers at the two facilities also did not follow the centers’ own training and staffing procedures.

Brooke Arndt, 27, a nurse who worked for a temp-agency, was on duty at the Spirit Lake care center when Elaine Creasey wandered away.

Investigators found Arndt repeatedly neglected to verify each hour that Creasey was in her room. Instead, she told investigators she just looked in the dark room and thought she saw the elderly woman in bed.

The alarm on the care center’s exit door sounded at 10:07 p.m. when Creasey walked out. Arndt went to the door 9 minutes later and shut off the alarm. But she did not check the residents’ rooms to see who, if anyone, was missing.

In both tragedies, there is plenty of blame to go around. Arndt told investigators she was never trained on how to properly perform the visual checks on residents at night. She also said she never received training on how to respond when the door alarm sounded.

At the Bondurant care center, Catherine Forkpa, 31, was on duty for the overnight shift when Lynne Stewart wandered away from the memory care unit.

Like Elaine Creasey, Stewart was supposed to be checked every hour because she was known to wander. But investigators said surveillance video showed that during Forkpa’s entire shift, she never entered Stewart’s room. Forkpa also was not recorded by any of the care center’s surveillance cameras for about three hours, investigators said.

When Stewart left her room and when she left the building, separate door alarms went off. Those alarms triggered alerts on a desktop computer shared by all employees, on tablet computers each worker was supposed to carry, and on the mobile phones assigned to the facility’s director and the on-call nurse.

Investigators learned the director and nurse both did not respond to text alerts about the unanswered alarms. Those text alerts continued every 5 minutes through the night while the two were at their homes.

Forkpa was fired for her actions. Four other employees were reprimanded for failing to investigate the door alarm alerts.

Now, the uncomfortable questions:

Dickinson County Attorney Amy Zenor apparently concluded Elaine Creasey’s death, and Brooke Arndt’s actions, were merely an accident. On the other hand, Polk County Attorney John Sarcone decided criminal charges were warranted against Forkpa in the Stewart death.

Sarcone’s staff chose to file a second-degree murder charge, which is punishable by up to 50 years in prison. Forkpa would have to serve 35 years before becoming eligible for parole. Sarcone could have filed the less serious charge of involuntary manslaughter, which is punishable by no more than 2 years of confinement or a fine of at least $625.

For Arndt, her punishment was much less severe. The Iowa Board of Nursing placed her on probation for one year and ordered her to complete 30 hours of additional training.

Toby Edelman, a policy attorney for the national Center for Medicare Advocacy, told Iowa Capital Dispatch, “The two resident deaths were tragic and avoidable. Many people in each facility are responsible and should be held accountable for their obvious failures to keep the residents safe.”

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Randy Evans can be reached at DMRevans2810@gmail.com

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