FLORISSANT • Part of Lois Moreland’s routine included a whirlpool bath before bed at the nursing facility she called home for at least three years.
The 88-year-old woman with Alzheimer’s disease nicknamed the whirlpool her “boat,” where she’d wash up before an assistant would take her to bed at St. Sophia Health & Rehabilitation Center in Florissant.
But after starting her bath about 8:30 p.m. on March 22, 2016, Moreland’s help never returned. It wasn’t until 4:30 a.m. the next day that a nursing assistant remembered taking her to the shower room hours earlier. Moreland's dead body was found in a tub of cool water with the whirlpool jets still running.
Now her son, Steven Moreland, is claiming in a lawsuit that the nursing home’s negligence caused his mother’s suffering and death and that St. Sophia put profits above health care by deliberately understaffing its 240-bed nursing home at 936 Charbonier Road.
“When there are not enough staff members to care for residents, it creates an environment where employees are trying to do too many things that they forget about putting a resident in a bathtub and end up leaving her there for over eight hours,” said Steven Moreland’s attorney, David Terry. He said Lois Moreland was “unable to comprehend her circumstances or fend for herself because there were not enough employees to meet the needs of each resident. And as a result, Lois Moreland paid the price.”
The nursing home is run by Creve Coeur-based Midwest Geriatric Management, which owns 22 facilities in Iowa, Wisconsin, Oklahoma and Missouri, including homes in Des Peres, St. Louis and Union, Mo.
St. Sophia was previously fined $80,427 in 2014 after a resident with Alzheimer’s disease walked away from the facility for more than two hours and was picked up by police a mile away. In 2016, one month after Moreland’s death, residents were temporarily evacuated from St. Sophia after a fire started in the laundry room. One worker suffered a minor injury.
Calls and emails to St. Sophia and its owner were not returned.
Lois Moreland had lived in the St. Louis area since the late 1960s and moved into St. Sophia in March 2013, according to her son’s attorney. She was a stay-at-home mother for most of her life and had been married for 59 years. At St. Sophia, her conditions included Alzheimer’s, dementia, depression, heart disease, hypertension, muscle weakness and difficulty walking.
The St. Louis County Medical Examiner’s Office attributed her death to natural causes, citing heart disease.
Moreland’s son believes that despite his mother’s poor health, she would not have died that day if she hadn’t been abandoned in the whirlpool, his attorney said.
An investigative report by the U.S. Centers for Medicaid and Medicare Services detailed the events based on staff interviews:
About 8:30 p.m. on March 22, a nursing assistant helped Moreland into the whirlpool tub and left the room when the woman requested privacy. The assistant said Moreland was typically left in the tub for five to seven minutes, with periodic checks.
On that night, the assistant went to help a resident across the hall who had fallen. Then other residents requested help, so the assistant “was very busy and forgot to check on the resident in the whirlpool tub.”
Between 4 and 4:30 a.m., the nursing assistant began collecting water pitchers from residents’ rooms and noticed Moreland wasn’t in her room. The nurse on duty told the assistant to check the bathroom. The assistant then remembered leaving Moreland in the tub the night before.
“Oh my God!” the nursing assistant said, and ran to the shower room. The assistant stood next to the tub, screaming and crying.
Moreland was “clearly dead.” The pull cord she could have used to summon help was dangling against the wall and beyond her reach, the report says.
St. Sophia had a nurse, two certified nursing assistants and a medication technician to care for 35 residents in the Honeysuckle Hill unit on the night Moreland died. There were 165 residents living in the entire facility at the time. The nursing assistant was assigned to Moreland’s unit only a few days earlier and felt “overwhelmed” by the workload, according to the federal report.
The investigation found that the assistant had a history of “negligent behavior towards residents,” the report said. In May 2012, the assistant saw a resident fall from a chair and told the patient, “I’m not gonna talk to you. I’ve been telling you to sit down all evening. I’m not gonna feel sorry for you.” The assistant was suspended one day by the nursing home. In August 2015, the same assistant was again suspended for one day after leaving a resident alone in the shower room. The resident fell in the shower while the assistant stepped out to retrieve more towels. A St. Sophia administrator told investigators that records of the incident were inaccessible because they were held by the nursing home’s previous owner.
According to the same report, Moreland’s doctor said it was unsafe to leave her alone in a bathtub for more than 30 minutes because of her declining mental and physical health. Her psychiatrist said she should not have been left unattended for longer than five to 10 minutes.
After Moreland’s death, government inspectors determined that residents at the facility were in immediate jeopardy, the most severe status given to nursing homes. St. Sophia was fined $39,260 and required to file a “plan of correction” that included never leaving a patient alone in the shower room, holding “team huddles” to share observations among staff, providing regular training to nursing staff, conducting regular checks on patients and reporting violations to the state immediately.