State Probing 38 Deaths at Nursing Home

California Department of Justice officials say they are investigating a series of 38 deaths among elderly patients over a four-month period in 1984 at a small nursing home in the Northern California community of Oroville but the officials caution against assuming that the probe will produce any indictments.

The current medical director of the 50-bed facility, the Gilmore Lane Convalescent Hospital, insists that the deaths were due to natural causes, mostly from flu during an epidemic. However, a medical consultant called in by the department to review patient records raised serious questions about the quality of treatment at the nursing home, according to documents obtained by The Times.

Insufficient Water

In particular, the consultant, a physician on the faculty of the University of California, San Francisco, reported that several of the patients were given far too little water by the nursing home staff, the documents show. The physician described the care at Gilmore Lane as “grossly negligent,” showing “a wanton disregard for (the patients’) lives,” according to the records.

Steve White, a chief assistant to Atty. Gen. John Van de Kamp, confirmed that the department’s investigation is under way, adding: “We’re looking at this closely. It will take a lot of time and resources, but we don’t want people to just assume that indictments will follow.”

Focus of Inquiry

Several sources familiar with the investigation say it focuses on whether the physician and staff at Gilmore Lane had done enough to ensure that each patient was receiving sufficient fluids. Blood tests of some patients indicated that they may have been suffering from dehydration so extreme that it could have killed them, according to the Justice Department documents.

Normally, seriously ill patients who cannot take fluids by mouth are given water and vital salts intravenously.

However, at Gilmore Lane, the documents say, several of the patients who died were given injections of water under the skin--a technique known as clysis that was once widely used but has been almost entirely replaced by intravenous delivery.

The records indicate that in several cases involving patients who died, not enough water was given to supply the daily need of about three quarts of water a day.

Dr. Neal A. Spiva, who became Gilmore Lane’s medical director after the spate of deaths, said the deaths were a result of a severe influenza epidemic that took an inordinate toll on a population of patients that included many extremely frail individuals.

Many of the patients had been discharged from a nearby acute-care hospital with the expectation that they would soon die, Spiva said.

Handled Critically Ill

“Gilmore, because of its proximity (to Oroville Hospital), handled lots of patients who had either terminal illnesses or were very elderly,” he said. “This is the only facility in the area that will take these critically ill patients.”

In an an earlier investigation of the deaths, begun in May, 1984, state Department of Health Services officials tried to determine whether forced-feeding techniques used at the facility might have caused patients to inhale their own food, said Patrick Buckley, who heads the department’s licensing office in Redding.

Inhalation of food or vomit can lead to pneumonia and would help to explain the large number of deaths, at least 25 of which were listed on death certificates as due to lung disorders--respiratory failure or pneumonia.

While several of the patients were very old--one was 98--many were in their 70s, and a few in their 60s.

‘Not Available for Comment’

The owner-administrator of Gilmore Lane at the time of the deaths, Herman Wohlfeil, could not be reached for comment. Win R. Richey, a Sacramento attorney who represented Wohlfeil in a successful appeal of a $5,000 citation against the facility, said Wohlfeil “was not available for comment.”

Wohlfeil sold the facility last month to Bryan and Sharon Jennings, the owners of a small chain of nursing homes. It is now operated by a new administrator and has been renamed Shadowbrook Convalescent Hospital.

Dr. W. R. Olson, medical director of the facility at the time of the deaths, also could not be reached for comment.

The Department of Health Services’ Buckley acknowledged that there was flu in the Oroville area in early 1984, but none of the other nursing homes in the area experienced such a large number of deaths.

Fed With a Device

He said that health officials called in after receiving an anonymous complaint were disturbed to find that aides at the facility were feeding some patients with a device designed to feed infants--one equipped with a plunger that lowers as an infant sucks pureed food out of a syringe.

The plunger is intended to keep an air bubble from forming, Buckley said, but health officials feared that it might have been used to speed the feeding of the elderly patients.

To learn whether the device contributed to the deaths of the patients would have required disinterring the bodies and performing autopsies, Buckley said. But he said that when state health officials approached the Butte County health officer about ordering a disinterment in May, 1984, they got nowhere.

Dr. Chester L. Ward, who is now health officer for the county, denied that his office had ever been approached.

Highly Critical Report

Without the information that could only have been provided by autopsies, state health officials could reach no conclusions about whether the feeding techniques contributed to the deaths. They did, however, issue a highly critical inspection report charging that administrator Wohlfeil “has not enforced the rules and regulations relative to the health care and safety of patients.”

The facility also was cited for an alleged failure to monitor the use of a powerful psychiatric drug used to restrain a seriously disturbed patient.

The citation would have resulted in a $5,000 fine. However, Wohlfeil appealed and the issue was reduced to a less serious offense and the fine sharply reduced. Under state law, such fines are never collected if the facility shows that it has corrected the underlying problem.

Between May and September, 1984, Gilmore Lane was required to report all deaths to the Department of Health Services office in Redding. But in that time, there were few deaths and no unusual circumstances, according to state records. The reporting requirement was dropped.

It was resumed again in February, 1985, a month after 11 patients at Gilmore Lane died in a period of a few weeks.

The Justice Department’s Medi-Cal fraud unit, which also has authority to investigate complaints of patient abuse, began looking at the 1984 deaths in February of this year.