A new report from the Oklahoma Medical Examiner’s Office confirms that a Sapulpa man died from choking on a trash bag while in the care of a state nursing home for veterans.
Leonard Smith, 70, was an advanced-dementia patient living in a locked-down special-needs unit at the Oklahoma Veterans Center in Talihina when he choked to death Jan. 31 after being given food, fluids and medication. After he died, a medical provider found that he had a plastic bag lodged deep in his throat.
In its final report on the death, the medical examiner determined Smith’s probable cause of death was asphyxia due to choking on a foreign body and the manner of his death was accidental.
The ME’s report revealed that included with items sent with Smith’s body to be examined was what was found in his throat: “a twisted clear trash bag covered in pink vomitus. The trash bag is intact and measures 24 (inches) in length and 1 (inch) in width when twisted. When the trash bag is untwisted, it measures 5 (inches) in width.”
Christine Cornwell, a Tulsa County resident and Smith’s niece, whom he had entrusted with his power of attorney, said the ME’s report may close a chapter in Smith’s death but not her and other relatives’ anguish over the circumstances.
“It’s just — this is crazy,” Cornwell said in a strained voice. “To have him there and that far away, we couldn’t go see him every day or every week with families and day-to-day living and him with dementia. To have this happen, it’s just neglectful, and they could have prevented it.”
She added, “I just pray that they’ve taken the proper steps to make sure this doesn’t happen to anybody else and nobody else’s family has to go through this.”
The Tulsa World began an investigation after the Oct. 3 death of Vietnam veteran Owen Reese Peterson, who was found with maggots in his body and later died from sepsis at the same Oklahoma Department of Veterans Affairs nursing home.
Health care workers from the highest to lowest levels of patient care at multiple ODVA-run nursing homes say the problems are systemic, not limited to Talihina.
The sources provided the World with detailed accounts and documentation of systemwide reductions in medical and nursing staff, outsourcing of lab work and one-size-fits-all, top-down medical directives and policy changes they said are compromising patient care and safety.
Investigators from the Oklahoma State Department of Health looking into Smith’s choking death found that the Talihina facility “failed to provide sufficient staff” to protect his safety.
They also found that higher-ups there failed to investigate low-level workers’ reports of an incident in November in which Smith passed a portion of an examination glove in a bowel movement.
ODVA officials have said that four employees of the nursing home have been reported to their respective licensing boards for possible disciplinary action in the case.
“We are still awaiting a decision from the licensure board,” ODVA spokesman Shane Faulkner said Thursday.
Smith served as a radar technician in the U.S. Navy for five years during the Vietnam War, earning the Vietnam Service and Vietnam Campaign medals. He had been a resident of the Talihina center, about 150 miles southeast of Tulsa, since January 2014.
His niece, Cornwell, said she was stunned last week to receive an invitation from Eva Dukes, administrator at the Talihina center, inviting family members to a Memorial Day ceremony there recognizing “residents that have expired at this facility since Memorial Day 2016.”
“I thought that was kind of odd,” Cornwell said.
She said she and Smith’s other nearest relatives are plagued by grief and even guilt.
“It’s the what-ifs you think about,” Cornwell said. “What if I could have been there every day? Would they have taken better care of him knowing that the family was coming in every day? Sometimes I think that has a lot to do with the care that patients get.”