7 Investigates: Nursing home fined for deficiencies creating ‘immediate jeopardy’ for residents

Daughter tells of 83-year-old Navy veteran who died after a visitor found him laying outside facility
7 Investigates: Nursing Home Nightmare
Published: Oct. 31, 2019 at 11:11 PM CDT
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TYLER, Texas (KLTV) - Christina Nelson can’t speak highly enough about her father, Marion Richardson.

“Well, my father Marion Richardson was an amazing man, a very accomplished man. Dad was an accomplished master knife builder. He was a farmer and a rancher. He did maintenance. Anything that needed to be done, dad did it,” Nelson said.

Nelson and her family were at a crossroads this past spring, one that is familiar to many American families: How to care for an elderly, aging parent.

After researching options for veterans, Nelson and her family moved their 83-year-old patriarch Marion Richardson into Reunion Plaza Health Care and Rehabilitation in Tyler.

“He was in danger and not safe at home anymore and we were not able to take care of his needs as he needed. He was a very large man, very tall,” Nelson said.

Richardson lived in the home for just more than a month. Nelson said her dad fell several times, once so hard that it required a hospital visit.

“[He had] a severe break in the upper part of his back and had had staples put in his head,” she said.

Nelson said each time her dad fell, someone at the facility would call her. After several calls were received, she drove the hour from her home to Tyler to speak with the staff.

“So, I even went, when I went back to the facility, asked the nurses, ‘what are you guys doing to prevent this?’” she said.

Texas Health and Human Services, charged with regulating and monitoring nursing homes and assisted living facilities, recommends the use of tracking devices on patients who are prone to wander or who may need special attention. The bracelet-like devices, referred to by the brand name Wanderguard, set off alarms when crossing a designated threshold, such as a doorway.

“They didn’t,” Nelson said. “They never had an alarm on my father.”

Nelson said just a short time after her dad was injured in a fall, Marion Richardson walked out a side door at the facility, undetected.

“And it did not have an alarm. He just walked out like he was walking right out of the door of his home,” Nelson said.

Nelson said the first she heard about the incident was when a nurse called to tell her that Richardson had been found.

“He had left the facility, and we found him, she said, quite a ways away. He had fallen in a mudhole and he had been wallowing around in it, and that he was so muddy when they got him out of it that they couldn’t tell if he had any injuries. ‘So, we have him in the shower now, as I’m speaking to you.’ And I said ‘what?’ I am horrified at this time, I’m speechless.”

Nelson said the next morning she was pulling into the facility’s parking lot to check on Richardson when her phone rang.

“She [a nurse] called to tell me right when I was driving into the facility that my father had collapsed, and he was unresponsive. I said, ‘I’m about 30 seconds from you, I’m running in,’” she said. “I threw my phone and I just ran into his room. And this was several hours after his fall ... my dad never woke up again.”

Marion Richardson died on June 20, 2019.


Though his name and some dates are redacted, a request for a Health and Human Services report related to Marion Richardson’s death returned information that matches Nelson’s story.

On July 3, a Health and Human Services surveyor visited the facility for an inspection.

The report says “Resident #1” wasn’t wearing a tracking device when he was found by a visitor outside the facility, lying on the ground. The report says Richardson was wet and muddy.

The report says the surveyor, “opened the exit door and the alarm did not sound.” When a different resident wearing a tracking bracelet was close to the exit door, it “did not alarm or lock.”

A maintenance supervisor is quoted in the report as saying the facility, “had no system in place to check exit door alarms.”

“The failure could place residents with unsafe wandering habits at risk of severe injury or death,” the report concludes.

Health and Human Services recommended a $15,210 fine for Reunion Plaza and ruled the facility out of compliance for participation in Medicare and Medicaid.

Changes were implemented almost immediately, according to the report. Staff received additional training, and a new door alarm system was installed.

By mid-October, a representative for the Health and Human Services department said the facility corrected the deficiencies within the required timeframe and the non-compliance finding was lifted. The fine was reduced to just under $9,000.

Reunion Plaza administrators declined a request for an interview but issued this statement:

“Our policies and procedures are designed to meet all state and federal requirements and the building is in-serviced regularly to monitor compliance.".

Nelson says it isn’t enough.

“This is what is so upsetting about the whole thing. He was no more safer in this professional medical facility than he was in our home with unprofessional people trying to do the best they could for him because we loved him,” Nelson said.

Her experience has turned into a driving force for change.

“We created a Facebook page called 'Justice for Marion’ and it’s about how we can all have a voice and come together with our stories about what has happened to our loved ones in nursing homes,” she said. “Because I bet just about everybody out there has known somebody in a nursing home who has been mistreated.”

Nelson said she is working with an advocacy group. She plans to present lawmakers with the stories she receives, hoping her experience with her father is never repeated by another family.

The guilt she feels about her father still hangs on her shoulders.

“This was an amazing man. And he didn’t deserve to go out this way,” she said, with tears falling. “That’s something we are going to live with the rest of our lives.”

To visit the Facebook page “Justice for Marion” click here.

To search a database of nursing home inspection results, click here.

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