Brandon Twp.- An investigation into the death of Carol Christie appears to be raising more questions than answers.
According to police reports, at about 8:27 p.m. on May 11, Brandon deputies were dispatched to a group home in the 7000 block of Oakhill Road. CPR was in progress on 66-year-old Christie, a severely mentally and physically disabled resident of the home since 1982, owned by Living Alternatives for the Developmentally Disabled (LADD). Upon arrival, deputies observed a Brandon firefighter attempting to calm down hysterical lone caregiver Wendy Marie Donaldson, a 25-year-old Ortonville resident. Oakland County Sheriff’s Detective Chris Pacholski also observed about 11-inches of water in the bathtub.
Christie was taken to Genesys Regional Medical Center and died there May 13 after being taken off a ventilator. An autopsy revealed the cause of death was anoxic encephalopathy caused by near drowning.
On June 8, Donaldson was arraigned on a charge of involuntary manslaughter and an alternate charge of vulnerable adult abuse, second degree, in front of 52-2 District Court Judge Dana Fortinberry, who set a $100,000 personal recognizance bond.
The case is being investigated by four different agencies, says LADD Executive Director Gloria Mitzelfeld? The Office of Recipient Rights (ORR), Protective Services, the Michigan Department of Human Services and the Oakland County Sheriff’s Office. Mitzelfeld said LADD is not researching what occured May 11 for fear of ‘muddying? the investigation of other offices. Now, conflicting details of what actually occurred that night are emerging.
The Citizen obtained through the Freedom of Information Act a special investigation report from the MDHS dated May 31 and sent to Mitzelfeld. The report addresses allegations that a resident (Christie) was left alone in the bathtub and drowned when only one staff member (Donaldson) was on duty.
An MDHS licensing consultant interviewed Donaldson and five other LADD staff members on May 15, including the regional supervisor, home manager, and assistant home manager as to the events that occurred May 11. According to the special investigations report, Donaldson (referred to as ‘Staff #1? in the report) said she placed Christie (referred to as ‘Resident A?) in the bathtub at approximately 7:15 p.m.
‘Staff #1 said that she left Resident A in the bathtub and would go and check on her every 10 minutes,? the report stated.
At the time the bath was begun, another staff member was still on duty, who, during the consultant’s interview, noted that Donaldson started a shower for another resident and left Christie in the tub. This staff member said she left at approximately 8:15 p.m., reminding Donaldson that Christie was still in the bathtub.
Donaldson said she was very busy that night. After the other staff member left at about 8:15 p.m., one resident pulled another out of his bed and Donaldson assisted another resident, who was returning to the home, to bed.
According to the report, Donaldson told the consultant she had once been told by the assistant home manager that it was OK to leave Christie alone in the bathtub, although she acknowledged there was nothing in writing and Christie was unable to bathe herself and needed full assistance. In the report, the assistant home manager denies she ever told Donaldson that Christie could be left alone and adds that all staff had been trained to understand Person Centered Plans for each resident of the facility, including Christie’s, whose stated that she required direct supervision when bathing.
Christie’s ‘person centered plan? was included in the investigative report and states that she should be within eyesight at all times and staff should know her whereabouts. It also noted that Christie ‘needs direct supervision during eating and bathing.? Further records on Christie show that she cannot bathe herself nor get out of the bathtub and would drink bath water.
Donaldson says in the report that she was familiar with Christie’s person centered plan and was trained on how to meet her care needs.
Donaldson also stated that when she found Christie not breathing, she started CPR and dialed 911, the report says. However, the home manager stated that when she arrived at 10 p.m., she noticed that none of the CPR bags had been taken out or used.
Ed Cibor, chief of the warrants division for the Oakland County Prosecutor’s Office, says Donaldson’s behavior, or lack of, on the night of May 11 resulted in the death of Christie.
‘In today’s world we have different homes and residential facilities and they are trusted to carry different standards,? he said. ‘Those standards are for the protection of people in the homes. Families should know those standards are being followed. If residents are placed in danger by an individual charged with the responsibility of looking after them, society has imposed penalties and will apply them.?
Donaldson’s attorney, Bradley Stout, has a different view.
‘I think it’s very unfortunate that a young woman like Wendy would be charged with such a serious crime when she was inadequately staffed and assisted by the company that owns the home,? he said. ‘It’s more their responsibility.?
The report notes that during the hours of 8-10 p.m., staff scheduling routinely showed only one direct care staff person on duty.
The investigative report found two violations relating to Christie’s death? staffing requirements and resident protection. The rules state that a licensee shall have sufficient direct care staff on duty at all times for the supervision, personal care, and protection of residents and to provide the services specified in the reisdent’s resident care agreement and assessment plan. An analysis found that Christie’s person centered plan indicated that she required hands on assistance with bathing and should not be left unattended. The report notes that Donaldson attempted to bathe two residents simultaneously on May 11 while working alone during the time of the incident.
‘Based on the six residents? functioning capacity, care needs and supervision needed, it was determined that the facility should have at least two direct care workers on duty at the time of the incident,? the report states, concluding that a violation has been established.
The report also says the applicable rule of resident protection (‘a resident shall be treated with dignity and his or her personal needs, including protection and safety, shall be attended to at all times in accordance with the provisions of the act.?) was also violated. Analysis concluded that based on the facility’s failure to provide direct care, protection and supervision to Christie, the facility did not assure safety and protect her from near drowning and ultimate death.
Deborah Wood, MDHS division director of adult foster care and home for the aged licensing, says there are different ways that staffing requirements can be established.
‘This (the Oakhill home) is a small group home and they are required to keep a minimum ratio of one staff member per six residents,? she said. ‘It’s an across the board requirement. However… they have to take the care needs of the residents that live there into consideration… You have to have enough staff to do everything that needs to be done. That is the bottom line.?
Wood went on to explain that Donaldson was bathing two residents at the same time, both of whom required direct assistance with bathing, and thus there should have been two staff members on duty at that time.
‘Because of the type of activity (Donaldson) was doing, there should have been two workers,? she said.
When questioned about whether the group home’s staffing is adequate, Mitzelfeld responded that staffing is difficult to summarize because it is an involved process on how staffing is determined.
‘It’s difficult to answer, it depends on the situation,? she said. ‘If they (residents) are going out in the community, if we’re doing a specific activity, it depends on what the personal needs are in a given situation.?
Mitzelfeld says one staff member can be sufficient for all six residents, but there is never supposed to be more than one bath or shower given at any time.
‘No one else should be getting a bath or shower when one resident is,? she said.
Kim Bishop, owner of the Nature’s Way Adult Foster Care Home in Brandon Township, says staffing for group homes is a common problem as budgets are cut. Bishop has owned Nature’s Way for two years, but has been working in adult foster care for 23 years and says employee turnover rate at the previous places she worked was about 70 percent.
‘We don’t have enough good people in this field, not for the money,? Bishop says. ‘We all know $8 an hour is crap… Should (Donaldson) have stayed in the bathroom? Probably in hindsight… If this young lady comes to work every day and tries to do everything right and has a client scream in another room, its a mistake that could happen to any person.?
She added that no matter how many staff members are on duty ‘it’s real life. You can’t shut off the assembly line. We’re working around other people. You have a job to do, and it becomes challenging.?
Margaret Cousineau, owner of Raspberry Manor, and AFC home in Goodrich, agrees.
‘We don’t know what the circumstances were,? she says. ‘How can you know what is going to happen when you have six people to take care of? There’s no way you can be all places at once. You might start a task and something happens. Now that woman is up for murder. It’s very sad, her life is ruined.?
Donaldson has been indefinitely suspended from working at the Oakhill home, where she has been employed since April 2005. Mitzelfeld says she has submitted a corrective action plan to the MDHS, which had not been received as of press time on Thursday. She summarized the plan by saying the actions administrators have taken are to clarify the training and information regarding people’s plans and to emphasize the existing rules.
‘The situation should not have occurred and our staffing procedures would not have allowed it to occur as they are written,? Mitzelfeld said. ‘Our staffing training more than adequately explains what needs to occur. The bottom line is, (Christie) should not have been left without direct supervision.?
A preliminary examination for Donaldson is set for 1:30 p.m., July 10, in front of Judge Dana Fortinberry at the 52-2 District Court in Clarkston.