A monitor attached to Jameir Benn’s toe should have alerted staff in a Buffalo nursing home that he had stopped breathing.
But on that February 2015 evening, only one worker in HighPointe on Michigan's pediatric unit was wearing a pager, and he did not respond to the urgent alert. When a nurse returned to Jameir’s room more than an hour later, the 16-month-old boy had choked to death on his liquid meal.
The toddler had been left alone hooked up to a feeding tube.
The state Health Department fined HighPointe $16,000 because nurses had not been wearing the required pagers that might have saved the toddler's life. The Health Department investigation concluded HighPointe failed to properly supervise the boy during his feeding.
Most of the 18 nursing homes in Erie and Niagara counties with poor ratings from the federal government are licensed to out-of-town, for-profit owners, The Buffalo News found in a six-month investigation.
But HighPointe is among the exceptions. It is owned by Kaleida Health, a Buffalo-based nonprofit. HighPointe has an overall two-star rating, "below average," in the federal five-star rating system for nursing homes. Only 10 of the 47 nursing homes in Erie and Niagara counties have a lower overall score.
"It doesn't matter what type of ownership operates the facility, out-of-town, for-profit, local, nonprofit or county. Every operator owes a duty to every resident they admit into their facility to provide safe and quality care," said Lindsay Heckler, a staff attorney at the Center for Elder Law & Justice in Buffalo, which often provides legal services to nursing home residents.
Nearly all of the local nursing homes fined by New York State are also operated by out-of-town, for-profit owners. But HighPointe is again among the exceptions.
In the last three years, the state has issued 28 fines to 16 nursing homes in the two counties. The $16,000 fine against HighPointe was the fourth-highest penalty the state imposed on a local home during that time.
Inadequate care, Heckler said, can occur at any facility, "if the staff is not sufficient, properly trained, and care plans for residents are not developed and followed."
Kaleida Health executives declined to comment on the death of Jameir because the company is being sued for his death.
But the company says that in recent years, it has hired the equivalent of 75 full-time workers, replaced 85 percent of its management and changed 60 percent of front-line staff. It now gets four out of five stars for staffing. It has increased its rating for the quality of care from two to five stars.
A state report on Jameir’s death noted that HighPointe has implemented steps to make sure there are a sufficient number of pagers for its staff and that a back-up plan is in place to monitor patients when pagers are needed.
"We are making strides in an extremely challenging environment and industry," said Michael P. Hughes, senior vice president and chief of staff for Kaleida Health.
But the nursing home still has the lowest possible rating at HighPointe in the category of “health inspections,” a one-star rating, or “much below average,” by the federal government.
State Health Department inspectors have cited HighPointe several times since 2015 for failure to provide proper care of residents. Citations include instances of inadequate treatment of bedsores, unsanitary practices while providing incontinence care, failure to provide medication, and serving food cold when it was supposed to be served hot.
Nurse left Jameir alone for about 75 minutes
Latifa Johnson, Jameir's mother, says her son died a terrible death.
Jameir, a triplet, was at the nursing home as a precaution. He ate liquids through a stomach tube and frequently suffered from respiratory illnesses because he and his sisters were born prematurely at 25 weeks.
On Feb. 18, 2015, his nurse removed him from his crib, fastened him into a high chair with a chest harness and connected his feeding tube to a pump attached to a hanging bag of liquid nutrition. She then left the toddler alone in his room. After he spit up, he choked on liquid nutrition that went into his lungs, according to his mother and the death certificate.
Johnson said Jameir's nurse told her in a phone call that she had found him unresponsive after leaving him alone for "a couple seconds."
But the Health Department investigation determined the nurse left the toddler alone for about 75 minutes.
The nurse, according to the investigation, returned to Jameir's room to check if the "feed" had been completed and, from outside his room, heard the monitor's alarm.
The nurse admitted to a state investigator that she did not have a pager with her.
The investigation determined that a respiratory therapist was the only person wearing a pager in the pediatric unit and that he did not recall if he received an alert. The therapist said he was attending to a "critical" patient when he heard his name "being called multiple times with increasing urgency" at about 5:30 p.m., the Health Department report stated.
"Within approximately one minute of last being called," the therapist said, he responded to Jameir's room.
Jameir's nurse, who is only identified as "RN #3," told state investigators that the HighPointe nursing staff was not required to carry the pagers. She also stated that none were available when she began her shift and that "the pagers are frequently broken."
Supervisors at HighPointe, the region's third-largest nursing home with 300 beds and the only nursing home in the region with a pediatric unit, offered a conflicting statement to the Health Department, saying that nurses should wear the pagers and that if one is needed it can be obtained within 30 minutes.
Much of Jameir's short life was spent in medical care
Jameir spent more than half of his short life in a hospital or nursing home.
For eight months after Jameir and his two sisters were born Oct. 9, 2013, he remained at Women and Children's Hospital because of an abnormally narrow air passageway and underdeveloped lungs.
But the plan was to bring him home, and Johnson received training at Children’s Hospital so that she could take care of his medical needs.
Those tasks included feeding, adjusting the tracheotomy device that provided warm moisture in his air passage and suctioning his respiratory system.
"In the training, they preached to me that when you feed him through the tube, you can't leave him alone. You have to make sure he does not aspirate," Johnson said.
Jameir, who was able to breath on his own, was released to the care of his mother on May 21, 2014, but he returned to Children's Hospital for treatment of a respiratory illness four months later. On Jan. 15, 2015, instead of discharging him home, hospital transferred him to HighPointe. Both facilities are owned by Kaleida Health.
Jameir's mother says she was pressured to go along with the transfer.
"I wanted to bring him home," Johnson said. But hospital officials told her the transfer to HighPointe was necessary because it was cold and flu season, Johnson said.
"They threatened me with Child Protective Services and said that he was going to HighPointe anyway," Johnson said. She said she didn't put up a fight to bring Jameir home because "I wanted to keep the parental rights to my son."
Nearly five weeks after he was admitted to HighPointe, Johnson got the phone call from Jameir's nurse.
"She said Jameir was having complications and I should meet him at the hospital. I said, ‘What kind of complications?’ and she said she had hooked him up to a feeding tube and left him for a couple seconds and when she came back he appeared to be unresponsive,” Johnson recalled.
After waiting two hours at Buffalo General Medical Center, Johnson said, she asked why she had to wait so long to see her son. A hospital worker said they were waiting for a police officer to arrive.
When she was finally able to see Jameir, Johnson said, "It was traumatizing."
Breaking down in tears, Johnson said, "I should have fought harder to keep him at home."
The Health Department found that HighPointe failed to conduct an "incident investigation" into Jameir’s death in the days that followed.
" 'When you review the record, you'll see why,' " HighPointe's assistant administrator explained, according to the state investigation report.
The state report noted that HighPointe's plan to correct violations related to Jameir's death included purchasing additional pagers and requiring all pediatric unit nurses and respiratory therapists to complete in-service training on use of pagers and what to do if a pager malfunctions.
Kaleida Health officials declined to comment on the death of Jameir.
“As we have said numerous times in the past about this incident, it is currently being litigated,” said Michael P. Hughes, senior vice president and chief of staff for Kaleida Health. “Moreover, out of respect for patient privacy, our organization will not comment on this matter.”
Lawyer says: 'This young disabled baby died a horrific death'
A year after her son died, Johnson sued HighPointe.
Johnson said her son should never have been left alone strapped in a high chair for more than an hour during the feeding. If a nurse had been present, she says, Jameir would not have died.
The pending lawsuit filed by Johnson's attorneys at Brown Chiari alleged that HighPointe lacked adequate staffing; failed to make sure nurses and other staffers on the pediatric unit wore "SafetyNet" pagers; and lacked a policy for the pagers.
"This young disabled baby died a horrific death," attorney Don Chiari said. "If they would have properly worn the pagers, they would have been notified immediately that something was going on."
The pagers, Chiari added, cannot take the place of a staff member monitoring such feedings.
According to the state investigation, other pediatric unit residents receiving tube feedings, as well, were not properly monitored.
The lawsuit also alleges a broader issue that reverberates in complaints from other families, patient advocates and nursing home workers: Children's and HighPointe, the lawsuit alleges, placed "profits of its parent company over the patient's medical needs and well being" in transferring Jameir to HighPointe, which it said lacked the ability to care for the toddler.
Roach, Brown, McCarthy & Gruber, Kaleida's attorneys, have denied the allegations in court papers.
Johnson says Jameir’s absence is not lost on his sisters, Lanyah and Naleyah, who are now 5. Johnson had an image of Jameir's smiling face tattooed on her upper left arm a month after his death.
"My daughters will walk up and kiss his face and say, 'I love you, Jameir,'” Johnson said. “They ask, 'When is he coming home?' But how do you explain that ..."
Contact reporter Lou Michel at firstname.lastname@example.org or (716) 849-4508.
Story topics: Nursing Homes