Fatal scabies outbreak was allowed to fester

February 3, 2018 GMT

Pat Lancaster moved into SouthTowne Memory Care in south Eugene in 2015 after she had been diagnosed with dementia. The 83-year-old from Toledo was becoming a little forgetful but still had times of lucidity and was otherwise in good health, her children recalled.

But less than seven months later, Lancaster was dead of an infection, having been found covered with large open sores that itched so severely, her family said, socks had been placed on her hands to keep her from scratching.

Lancaster’s family says she was one of the dozens of residents at SouthTowne between 2013 and 2016 who were plagued by severe and recurring outbreaks of scabies, a tiny parasite that bores into the skin, causing intense itching and inflammation.

Untreated, the parasites can dig tiny tunnels over wide areas of the body, leading to large, crusted sores, infections, insomnia, weight loss and much worse. State nursing officials eventually found scabies may have been a contributing factor in three patient deaths at SouthTowne.

Yet the highly contagious parasite can be easily and inexpensively eliminated with anti-parasitic ointment, and regular bathing and cleaning.

Pat Lancaster “went to the (emergency room) because of a fall,” her son, Art Lancaster, recalled tearfully in late December. “But she never went back to (SouthTowne) after a hospital charge nurse saw what was all over her. It was so bad.”

“She had open sores all over her whole body,” Pat Lancaster’s daughter Julie Warfield of Toledo said. Staff members at SouthTowne, she said, “told me it was just a rash.”

Pat Lancaster was transferred to a burn unit in Portland where a team of nurses worked to clean her for three hours, her son said. “They almost had all of the outer part healed when she died because the infection was so bad inside of her,” Art Lancaster said. “She never had skin problems before (SouthTowne).”

The state Department of Human Services eventually concluded that administrators at SouthTowne had hid scabies outbreaks from state inspectors for years.

That inquiry found that many patients had suffered from scabies infections but was silent on whether scabies was a contributing factor in any deaths.

Even after state inspectors in August 2016 learned of the latest widespread outbreak, it took the state nearly a full year, until spring 2017, to force the facility’s owners and management to eliminate the scabies problem.

The investigation and oversight was carried out by the Aging and People with Disabilities program of the state Department of Human Services.

The state works “collaboratively” with care homes, and when a facility fails to correct violations, the agency takes progressively tougher actions over time, spokeswoman Elisa Williams explained.

“I itch all over”

A severe scabies outbreak afflicted residents and employees at SouthTowne Memory Care while Lancaster was a resident in 2015, and facility administrators falsified and destroyed documents to cover up the outbreak, according to the state’s later investigation.

Scabies led to or contributed to the deaths of a least three residents in fall 2016 and caused months of suffering for dozens of other residents, the investigation found. The parasite spread to facility staff members and their families, according to the investigation by Aging and People with Disabilities.

Six months after the state launched that investigation, SouthTowne still was not in compliance, state records show. The facility had to completely overhaul its management team in February 2017 at the state’s direction.

“I itch all over,” an employee told state investigators. “I know it is scabies because I have had it so many times from working there. Most of the staff are itching like crazy, and no one can sleep at night. If we show it to (administrators), (one) just says to put anti-fungal cream on it and (one) says it’s because staff are not showering ourselves daily. Give me a goddamn break!”

Anti-fungal creams do not treat scabies.

State begins inquiry

The state launched its investigation in August 2016 after receiving a tip that three residents were suffering from scabies and one of the three was “actively dying.”

In the following two months, while investigators were probing the facility, three residents with the disease died. The state’s records related to those deaths were obtained under Oregon public records by The Register-Guard this week. The investigation ultimately led the state to levy $39,500 in fines against the facility and to bring criminal charges against its then-executive director, David Scott Meisner, 50, and then-director of health services, Jandyra Dubofsky, 35. Both were charged with first-degree criminal mistreatment, and both have pleaded guilty.

SouthTowne Memory Care, at 389 W. 29th Ave. in south Eugene, is owned by Ageia Health Services LLC, a private company based in Bend. State records do not show the name of the individual or individuals who actually own the company. Records list Kevin Cox of Bend as the agent and a member of Ageia.

“When we became aware of the nature of this (scabies) problem, we took immediate action as far as terminating David and the nurse,” Philip Emerson, the company’s general counsel, said Thursday. “Obviously, there was an issue — and I am not going to characterize it beyond that, but the point we would be interested in making is that we have returned to a situation at SouthTowne where we are back in compliance. It’s news this week or it’s news this month because of the criminal outcome of the case. At this time, we are back in full compliance, and that’s what’s most important to us.”

Fines and sentences

Emerson said SouthTowne had 55 residents in September 2016, with a majority of clients referred by Medicaid, the federal government health program for low-income and disabled people. After the state investigation, Medicaid stopped referring clients to the facility, Emerson said. The facility currently houses 37 people.

Emerson said Ageia did not contest the $39,500 fines. A chart provided by the state late Thursday shows Ageia still owes $22,300 in fines.

Meisner pleaded guilty to the felony charge earlier this week and was sentenced to 60 days in jail, with alternatives available, meaning he could apply for programs such as work crew. He also is expected to transfer his sentence to Washington state, where he now lives. Meisner also was fined $200 and is on supervised probation for three years. He’s required to participate in any Medicare fraud investigations related to this case.

Dubofsky, a registered nurse, pleaded guilty to the charge last month and was sentenced to three years of supervised probation in Lane County Circuit Court. She has been suspended from nursing for one year and will be on probation for two years, according to the Oregon State Board of Nursing. In its written decision, the board states, “SouthTowne Living Center residents suffered from ongoing itching and skin irritation, directly related to the lack of adequate showering and nail care. Due to the fragility of this patient population, this led to infection, skin breakdown and a possible contributor to at least three patient deaths.”

“I want to die”

The names of the victims are not provided in the report by the Aging and People with Disabilities program. They are referred to only as “reported victim” and a number. But the prolonged suffering and infection related to the scabies infestation contributed to their deaths, according to the report.

Administrator names also are not included in the report; they are referred to as “reported perpetrator.”

SouthTowne administrators “spend so much energy hiding things and it would honestly make more sense to just deal with the real issues,” an employee told investigators. “Residents don’t get showered at all.  …  I honestly think that (administrators) think that if word gets out again that (SouthTowne) has scabies that they might be in trouble. (An administrator) actually says all the time, that it’s not a bad thing to have scabies. (An administrator) tries to drill that into our head. One resident was itching and crying and said, ‘I want to die so I don’t itch like this.’  ”

Scabies are highly contagious but relatively easy and inexpensive to treat with two applications of a skin medication and washing. The mites also can be killed using oral medications.

Hoarding treatments

A number of employees told investigators that the facility’s administration “stockpiled” the anti-scabies creams that were intended for the residents in a locked desk drawer in an office, and instead used them for themselves and occasionally for staff members. Records show 19 tubes of the prescription cream were ordered for SouthTowne’s “house stock,” without a physician’s order, from 2011 to 2015.

Meisner initially was charged with identity theft for allegedly using the identity of a physician. The identity theft charge against Meisner was dropped as part of his plea deal.

Other times, staff were told to use anti-fungal cream on themselves. The cream temporarily stopped the itching but did nothing to rid them of the parasites, according to the investigation. The scabies disease also was explained away by administrators as “dermatitis” or an allergic reaction to soap, records show.

“I am worried for the residents. I have never seen it this bad,” one employee told investigators, adding that administrators told staff members when they complained about their working conditions that “it’s natural to have scabies.”

“They don’t pay us for the extra cost of going to the doctor, missing work, paying for the medicine, all the extra money we spend on laundry just trying to cure ourselves. And for what? We’re just going to get it again because everyone in the building is itching with scabies. I have children!” one staff member told state investigators.

Scabies outbreaks have occurred at SouthTowne as far back as 2013, according to the state’s investigation.

“No one was every fully treated (in 2013) because there were not enough lotions,” an Adult Protective Services supervisor told state investigators. “(An administrator) kept stash of lotions in (their) office for staff.  …  (SouthTowne) had scabies for sure from 2013-2015. I’m glad it’s finally coming out.”

Very aggressive form

Scabies can be hard to diagnose the longer it goes untreated and when the patient is elderly, according to the state’s report. In a person with a healthy immune system, a liquid such as iodine can be applied to the skin, then with the help of a flashlight and a magnifying glass, scabies tunneling tracks can be seen under the skin. In an elderly person, the tunneling marks are harder to see.

The type of scabies that affected SouthTowne, the report states, was crusted Norwegian scabies, a more severe form of the disease.

Scabies can result in lack of sleep and loss of appetite, because the patient is so uncomfortable, the report reads. The patients at SouthTowne, documents show, lost a significant amount of weight as a result of the skin irritation and were starving. SouthTowne staff members offered patients “health shakes” — a mixture of protein powder, Crisco shortening, pudding mix and whole milk, the report states.

One of the victims who died during the investigation was down to about 95 pounds.

“It is heartbreaking that these seniors have to suffer like this,” one employee told state investigators.

Misleading relatives

After receiving the tip in August 2016, the state agency sent investigators to the facility to conduct face-to-face interviews with the victims and each staff member, many of whom also suffered from scabies. In all, investigators interviewed 28 witnesses.

“(They’re) covering up a scabies problem,” one employee told investigators.

The stories of each employee were alike and revealed that the three patients with scabies were just the tip of the iceberg — an ongoing problem that had plagued the facility for years.

Victim 1’s “hands are crusted on the palm and dark brown. (An administrator) is trying to tell the hospice people that it started this week, that the hand issue is brand new which is not true, both (Victim 1’s) hands have been crusty and dark for a long time.”

“The scabies are eating (Victim 1) alive,” another employee said.

Victim 1 died Sept. 1, 2016, during the state’s investigation.

According to a staff member, Victim 1’s adult child was traveling from California to visit on the day Victim 1 died, and the staff was instructed to intercept and bring the relative straight to an administrator’s office to talk about the victim’s hands, allegedly to say a sudden fungus had appeared overnight. “I could not believe it,” the staff member told investigators. “That was a total lie.  …  (Victim 1’s) hands were brown, dark brown and thick and crusty for many, many months. (Victim 1) was uncomfortable for a very long time. … (The administrators) are monsters.”

The facility was fined a civil penalty of $2,500 related to the abuse and neglect of Victim 1.

Less than three weeks later, another victim would die, a man who had been able to care for himself independently a month before his death, but he deteriorated rapidly, which led to his being admitted to a hospital.

At the time of his death, the victim had nine wounds and open sores, had dead black tissue on his genitals, and was septic — infected with bacteria — and unresponsive, the report states. One month prior, during the state’s investigation, an investigator said the man had been lucid and spoke about his itchy rash.

But the day before the victim was taken to the hospital, a staff member wrote in the facility’s “skin book,” — a system used to record observations related to the skin rashes — that his genitals showed “redness.”

“Necrotic tissue doesn’t just happen overnight,” a staff member told investigators.

When the staff member who wrote “redness” in the book was interviewed by investigators, the employee asked, “Do I need a lawyer? Should I look for another job in nursing?” according to the state’s report.

The facility was fined $15,000 as a result of that victim’s death. In the days before the man’s death, Meisner and Dubofsky both left the facility.

Third patient dies

A third victim died Oct. 31, 2016, but that death did not result in a sanction or penalty, as no Oregon Administrative Rules were found to have been violated. However, the facility was alleged to have failed to provide oversight and monitoring of the person’s change of condition. The victim was suffering from scabies.

“I know (the victim) had been treated a lot more than most residents for scabies,” an employee told investigators. “I think (the victim) still had scabies or was recovering from it when (the victim) passed.”

SouthTowne Memory Care now has a new management team, and Valarie Zito is listed on the website as the new executive director. She did not return a call or email request for comment.

Follow Chelsea on Twitter @ChelseaDeffenB . Email chelsea.deffenbacher@registerguard.com .