SEATTLE – Some fell to the floor and bled to death internally. Others choked on food and suffocated. Still others languished for weeks as bedsores burrowed to the bone, ultimately killing them.
In neighborhoods throughout Seattle and across the state, hundreds have died prematurely, many in avoidable misery, while living at state-licensed adult family homes.
A Seattle Times investigation has uncovered at least 236 deaths that indicate neglect or abuse in these homes but were not reported to the state or investigated.
Dozens of suspicious deaths occurred in adult homes with long histories of violations, including some whose owners employed caregivers with little training or forged credentials.
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In the first accounting of such deaths, The Times identified these cases by analyzing death certificates of 4,703 Washington residents who died at adult homes from 2003 through 2008.
Adult homes are a less-regulated, less-expensive eldercare option than nursing homes, and are touted as providing personalized care in cozy, neighborhood settings.
But The Times also found that adult-home deaths indicating neglect occur at strikingly higher rates than comparable deaths at nursing homes:
-Pressure-sore deaths in adult homes occur at a rate more than 3.5 times higher.
-The rate of deaths from falls is four times higher.
-For choking deaths, the rate is 15 times higher.
Adult family homes are regulated by Washington's Department of Social and Health Services (DSHS), which licenses home owners to rent out spare bedrooms and provide long-term care for up to six seniors.
This housing option, which has boomed since the 1990s into a patchwork of 2,984 privately owned homes today, has earned the state a national reputation as an innovator in providing community-care choices for the elderly. Dozens of states plan to emulate Washington's program.
There is a dark side to that business boom. DSHS, for example, doesn't track how many residents die in the homes each year or question the circumstances.
The industry has expanded so swiftly and with so little oversight that it has attracted profiteers who, until The Times exposed the practice earlier this year, freely marketed homes and the residents as good investments.
Kathy Leitch, DSHS' head of aging and disability services, said that most adult homes provide safe care and represent an important option and first choice for many seniors.
Cindi Laws, executive director of the Washington State Residential Care Council of Adult Family Homes, said only a small fraction are problem homes.
None of the 236 deaths came to the attention of DSHS, records show. When such cases do get reported to the agency, Leitch said, it investigates them and routinely refers evidence of possible crimes to law enforcement.
But in dozens of cases, DSHS ignored or excused reports of suspicious deaths, including statements from witnesses, The Times has found.
By law, all caregivers are required to report suspected abuse of the elderly to DSHS. However, King County Medical Examiner Dr. Richard Harruff said he's learned, well after the fact, of elderly deaths that his office would have chosen to investigate. "Getting people to report seems to be a problem," he said.
Retired dairy farmer Clarence Yesland, 84, had struggled with Parkinson's disease and dementia for a decade until he became too frail to live at his Kirkland home. His wife, Marie, 82, moved him in 2004 to Houghton Lakeview adult home, also in Kirkland.
The five-bedroom home, blocks from Lake Washington, was licensed to owner Patricia Goodwill. She billed $3,500 a month for room and care.
"We thought the home was excellent," said Yesland's stepson, Gary Gelow, 67, of Kirkland.
What family members didn't know until much later was that the home, while Yesland lived there, had been cited for more than a dozen serious violations during DSHS' inspections.
One resident had not received enough fluids and was dangerously dehydrated. Caregivers considered another resident too active, so he was forced to consume anxiety medications prescribed for a different person.
Three staffers had convictions for felonies - assault, drug possession and child abuse - which by law should have disqualified them from working with vulnerable adults.
In January 2008, Yesland's family was told Clarence had fallen in the kitchen. The family would later learn that his primary caregiver, a woman they trusted named Effie Dutton, may have delayed getting any care for him for two days or more, worried about losing her job.
"We never did get a good explanation about how he fell," Gelow said.
After finally being taken to the hospital, Yesland was found to have a broken hip. But he was too weak to endure major surgery, his dementia was much worse, and he was unable to communicate coherently.
Yesland was given a narcotic to dull the pain from his hip. But Dutton told members of his family that the drug would hasten his death, Gelow recalled.
At the time, he was unnerved by Yesland's rapid decline from being active to spending all his time curled in a ball in bed.
"She said that these medications put people into vegetative states and they die more quickly," he said.
Dutton said that, as a favor to the family, she would not give Yesland the narcotics but falsify his medical record to show that she had, Gelow said. Trusting her, he agreed to the plan because he wanted his stepfather to live longer. Yesland died a month after breaking his hip.
A short time later, DSHS received a five-page, typewritten letter that described widespread abuse and neglect inside the Houghton Lakeview home. The letter was signed by Dutton's husband, Robert.
He and his wife had lived in the basement of the home for two years. Dutton wrote that his wife had pocketed prescription drugs from Yesland and several other residents. She told him that she had fabricated medical files to cover up the thefts and sold the pills to a caregiver with a drug problem at a different adult home owned by Goodwill, he wrote.
As proof, he later provided empty vials of the residents' medications, which he said he found in his wife's dresser.
Dutton also wrote that his wife had confided to him that Yesland was not promptly treated after falling, and that internal bleeding may have contributed to his death.
Dutton, who is now divorced, said he finally came forward because he couldn't live with the guilt and that it "made me sick to think of all the residents dying."
Gelow recently reviewed DSHS records and Robert Dutton's letter, provided by a Times reporter. Gelow said he was "stunned" to learn that Effie Dutton had been cited for using a forged nursing assistant license. DSHS considered it a minor violation because adult homes are not required to have licensed caregivers.
Gelow believes that Effie Dutton likely diverted the drugs, resulting in unnecessary pain for his stepfather, who, with his dementia, could not communicate at the end of his life.
Gelow said he feels guilty. "Now I realize how I was duped," he said.
DSHS failed to investigate Robert Dutton's accusations about drug thefts and sales, records show. Nor did DSHS, or any agency, look into Yesland's death.
Dutton dropped another bombshell in his letter to DSHS: An elderly woman died from neglect just months after Yesland's death.
In May 2008, Dutton wrote, he received a panicked phone call for help from his wife. She had a medical emergency at the home with a female resident, but was afraid to alert 911.
The woman was Jean Rudolph, 87, a retired nursing educator who had Alzheimer's disease and heart problems. She had moved there six years earlier from her nearby home.
When Robert Dutton arrived, he learned that Rudolph had seven pressure sores, some so deep that muscles and bone were exposed.
"So we stripped Jean naked and the smell and her clothes were so bad, I opened the window and started gagging. Effie was gagging too," he wrote. "Jean's diaper was totally full of urine and poop and it looked like she hadn't been changed for at least 24 hours.
"When we stripped her down, I looked at the sores and they were very red, inflamed and very infected. Jean was screaming loudly when Effie touched her sores and was fighting but I kept talking to her and trying to distract her."
The Rudolph family had been told nothing about her pressure sores for 22 days, DSHS records show. Rudolph's son, James, said when Dutton finally called him about his mother's condition, he immediately went to the home and transferred her to the emergency room. It was too late - infection from the bedsores had spread to her vital organs.
Jean Rudolph died in June 2008 at her son's Bellevue home under hospice care.
"I think there's really a lot of guilt," said James Rudolph, 56, a Bellevue architect. "You kind of feel like: My God, how did this happen?"
The family contacted DSHS repeatedly about what happened to Jean at the adult home. DSHS eventually sent an investigator, who determined that Effie Dutton, instead of monitoring residents, often trolled the Web on her laptop computer, conducting a relationship with a man overseas via chat rooms and e-mails.
Dutton and Goodwill, the owner, were each charged with one felony count of criminal mistreatment for failure to provide proper care to Rudolph. Dutton, who remarried and was charged as Effie Tutor, pleaded guilty last month and awaits sentencing. Goodwill's case is pending. Both declined to comment.
DSHS now requires adult homes to publicly post copies of violations. The agency made this change in February, shortly after The Times' investigation showed how families were kept in the dark about a home's violation history. In addition, DSHS now lists violations for adult homes on its website.
The Times identified at least 29 adult-home deaths that were linked to advanced pressure sores.
In 2008 alone, three retirees in Puget Sound-area adult homes died from complications of advanced pressure sores: a Lynnwood hairdresser, 93, who had multiple sclerosis; an Everett homemaker, 93, with heart disease; and an Issaquah homemaker, 91, who had severe dementia.
None of the cases was reported to DSHS.
Asked about this recently, DSHS' Leitch said she is concerned that many cases of "elder abuse and neglect are not reported."
Pressure sores, also called bedsores, commonly plague seniors who are bedridden or rely on a wheelchair to get around.
Researchers disagree over how the sores develop - above or below the skin - and even how quickly they advance. Constant pressure against the skin, especially along bony areas, may reduce blood supply and kill tissue.
Sores have four classifications: a reddened area of the skin (Stage 1); a large blister (Stage 2); an open wound (Stage 3); and finally, a gaping wound with exposed muscle, tendon or bone (Stage 4).
Most medical professionals believe that Stage 3 or 4 pressure sores are likely signs of neglect.
If detected early, the sores are treatable with ointments or powders. But constant vigilance is needed. To avoid prolonged pressure that can develop sores, doctors sometimes require at-risk seniors to be shifted every one to two hours, particularly at night, which requires a well-staffed home with diligent caregivers.
Health care research conclusively links higher staffing to lower fatality rates. It's a simple formula: More caregivers equals better care.
With nursing homes, the federal government has stepped in and mandated minimum levels of staffing, including a requirement of 24-hour care overseen by a registered nurse.
But Washington's adult homes are not regulated by federal law. And Washington law, so far, hasn't required adult homes to follow the dozens of safety standards required of nursing homes.
For example, an adult-home owner or sole staffer is not required to be awake at night when overseeing as many as six residents. Owners and staffers aren't even required to have a minimum health care license, such as that of a nursing assistant.
State ownership rules are so loose that some adult-home owners are business investors who have no prior health care experience, buying and leasing adult homes like fast-food franchises.
Washington legislators have tried but failed to fix some of these problems. The adult-home industry has opposed additional staffing requirements as unnecessary and too costly.
Lawmakers have been reluctant to impose tougher measures on what they often perceive as mom-and-pop enterprises.
For nearly a decade, Washington's rate of accidental deaths in adult homes and nursing facilities remained the same, about one out of 50 deaths. But the accidental-death rate for adult homes jumped 50 percent in 2007, and again the following year.
Adult-home residents now die from accidents at twice the rate of those in nursing homes, a Times analysis of death certificates shows. A key reason centers on the declining number of caregivers at homes. During this economic recession, scores of owners have cut staff and services to stay afloat, adult-home industry officials said.
State records reveal a pattern of problems during night shifts at adult homes. For example, in November 2007, a Seattle adult-home resident, 77, was found dead in his room. A catheter had dislodged from his arm and he slowly bled to death unnoticed during the night, according to DSHS, which received a complaint about the incident.
In another case, at a Kent adult home last year, a caregiver discovered an unconscious woman sitting in her wheelchair in the kitchen. The 61-year-old woman had accidentally taken too many prescription drugs. The caregiver wheeled her to her room. Not strong enough to lift her, the caregiver rolled the comatose woman onto the bed, face down. She was found dead in the morning.
In health care, these kinds of deaths are called "failure to rescue," meaning the deaths would have been avoided if a caretaker had noticed the problem and taken the correct action.
Choking to death on food falls into this category. The elderly often have trouble swallowing, a condition caused by dozens of medical maladies that interfere with this seemingly simple task.
Caregivers are required to properly prepare food, such as cutting hot dogs into small pieces, and then to monitor residents' mealtimes. But many homes employ just one caregiver during the day, making it difficult when overseeing six residents, the maximum allowed per home.
The Times identified seven adult-home residents who choked on food and suffocated from 2003 through 2008. In contrast, nursing homes, which have many more residents statewide - about 17,000, to adult homes' estimated 11,000 - had only one choking death.
The Times identified 128 adult-home residents who died from injuries related to falls but whose cases were never investigated. Among those who died, all from head injuries, were a retired seafood distributor, 94, of Darrington; a former Spokane medical tech, 94; and a retired Renton teacher, 88.
Not all accidental deaths can be prevented. But such deaths, at the very least, should spark a review of care at the homes, said Seattle police Detective Suzanne Moore, who specializes in investigating deaths of the elderly.
In 2006, King County prosecutors, the medical examiner and Seattle police came up with a plan to review adult-home fatalities. They believed that some were likely caused by neglect but had not been reported as suspicious deaths, said Harruff, the medical examiner. A Seattle police detective planned to visit each Seattle adult home when it had a death.
But the idea faced instant opposition. Families were apprehensive about privacy. Owners feared unnecessary disruption. Physicians worried about second-guessing from medically unsophisticated police officers.
"There was just huge push-back," said Detective Moore, part of the review team. "There were those who didn't want the police responding to every death."
Today, Harruff is trying again. He's collaborating with researchers at the University of Washington, which obtained a federal grant to examine deaths in all long-term-care settings, and they plan to publish their findings next year.
Autopsies, which are reserved for unexpected, violent, suspicious or unnatural deaths, are performed in about 10 percent of the state's 46,000 annual deaths. For adult-home deaths, which typically are not unexpected, the autopsy rate is just 1 percent, a Times analysis shows.
Barring an autopsy, the cause of death listed on a death certificate often represents a best guess, based on medical history. Frequently, the dead are not examined by physicians. So when doctors sign death certificates, they may be unaware of recent injuries, such as pressure sores or hemorrhages from falls.
As a result, the number of suspicious deaths at adult homes is almost certainly higher than the 236 identified by The Times.
In the case of Clarence Yesland, the physician who signed the death certificate had last examined him weeks earlier. Yesland's body was transferred directly from the adult home to a funeral home, then cremated.
Gelow said he and his mother are upset that DSHS kept them in the dark and then failed to pursue evidence of neglect.
"The state closed this case and never asked me or my mother a single question," Gelow said. "It makes you wonder how many times they've done this."