State Finds No Criminal Acts in 39 Deaths at Nursing Home

Despite evidence suggesting “medical improprieties” at an Oroville nursing home where 39 patients died in a five-month period, Atty. Gen. John Van de Kamp concluded Wednesday that there is “insufficient evidence to show that any died because of criminal wrongdoing.”

After more than a year of investigation into the deaths two years ago of elderly patients at the 50-bed Gilmore Lane Convalescent Hospital, Van de Kamp in a report said there was no point in pursuing the cases further.

In explaining the decision to close the investigation, the report cited conflicting opinions among medical experts about the quality of care at the nursing home and an inability to determine the actual cause of death, because no autopsies were performed.

“Though the evidence and expert opinions suggest certain medical improprieties with respect to at least some patients, it cannot be established that criminal negligence proximately caused or hastened the death of any patient,” Van de Kamp said.

Unusually High

The attorney general’s investigators looked at a total of 48 deaths at the nursing home--39 between Dec. 4, 1983, and May 1, 1984, and an additional 9 in January, 1985. In both periods, the death rate was unusually high in contrast with the 16 deaths at the same facility in all of 1983.

The report noted “areas of concern about the nursing home industry in California”--particularly the placement of seriously ill patients in nursing homes, rather than in full-service, acute-care hospitals.

In addition, the investigators criticized Department of Health Services licensing officials for waiting nine months to inform law enforcement authorities about suspicious deaths at Gilmore Lane. The investigators also complained that the licensing officials needed training in writing reports and preserving evidence.

Some of the physicians who reviewed the dead patients’ records were critical of state and federal health care policies that limited doctor visits to patients and may have encouraged the premature discharge of patients from nearby Oroville Medical Center to Gilmore Lane. The medical experts described the nursing home as ill-equipped to care for seriously ill individuals.

Since the outbreak of deaths, Gilmore Lane was sold by Herman and Melody Wohlfeil and is currently operating as Shadowbrook Convalescent Hospital.

Quality of Care

Six physicians quoted in the report who reviewed the patient records for Van de Kamp could not agree on either the quality of care or the cause of death of the patients.

Two of the physicians, Dr. Alan Arieff, a professor at the University of California, San Francisco, and Dr. Philip Weiler of the University of California, Davis, said they were convinced that the care given patients at Gilmore Lane was below acceptable standards.

Both raised questions about the conduct of the nursing home’s former medical director, Dr. Wilfred Olson, who was responsible for the care of 22 of the patients who died.

Weiler concluded that Olson’s “practice of medicine at Gilmore Lane can be equated to malpractice,” the report said. He and Arieff criticized Olson’s failure to respond quickly and appropriately to the condition of his patients.

Arieff also concluded that in five cases he reviewed, the patients died of dehydration, because they were being given fluids in a way that may have worsened their condition.

Another expert, Dr. Boyd Stephens, San Francisco’s chief medical examiner, questioned Olson’s diagnosis of patients and his choice of treatment, but he praised the quality of nursing care at Gilmore Lane as “good to very good,” according to the report.

Olson, who has retired from practice, told investigators that many of the deaths in early 1984 were caused by what he believed was a viral epidemic affecting the heart, the report said. He said critically ill patients were not transferred to Oroville Medical Center, because he believed that the hospital would have returned them immediately to Gilmore Lane.

His successor as medical director, Dr. Neal Spiva, agreed with Olson’s assessment, the report said. In some cases, Spiva told investigators, he and other physicians on the staff decided to take what the report characterized as a “let-nature-run-its-course” approach to the care of some elderly patients, after consulting with families.

Department of Health Services physicians quoted in the report generally defended the nursing home and its doctors, including Olson. The department’s senior medical consultant, Dr. Burke Schoensee, noted that the 32 records he reviewed were of patients ranging in age from 64 to 98, and all but six were over 80.