Catherine Forkpa, a former caregiver at Bondurant’s Courtyard Estates at Hawthrone Crossing, is charged with second-degree in the death of a resident at the assisted living center. (Photo illustration by Iowa Capital Dispatch. Photos by Polk County Jail and Clark Kauffman/Iowa Capital Dispatch)
Two Iowa caregivers accused of failing to protect elderly Iowans who froze to death on their watch are now facing very different consequences.
One of the workers has been criminally charged with second-degree murder and faces up to 50 years of imprisonment if convicted, while the other is facing no criminal charges and has been allowed to keep her nursing license.
The murder charge is highly unusual for a case involving a care-facility worker accused of neglect.
“I can’t say definitively that the state has never charged anyone with second-degree murder in these circumstances, but if they have, I am not aware of it,” said Matthew S. Sheeley, an assistant state public defender who is working the case.
“The two resident deaths were tragic and avoidable,” said Toby Edelman, senior policy attorney for the nonprofit Center for Medicare Advocacy and a nationally recognized expert in senior care. “Many people in each facility are responsible and should be held accountable for their obvious failures to keep the residents safe.”
“Every Iowan should be concerned about these tragic deaths,” said John Hale, a consultant and advocate for older Iowans. He said while Iowans should insist on justice for the families involved, “all too often, it’s the direct-care staff members that get blamed for these tragedies — and in some cases, that may be warranted if they failed to act when they could have.”
He said in many cases, facilities have a lack of sufficient staff, provide scant training, or use temporary workers who are not familiar with residents or the facility’s procedures. “When those additional factors exist, the responsibility for tragedies goes beyond the direct care staff on duty – it also goes to supervisory staff, facility management, facility owners and corporate directors,” he said.
The first of the two cases involves 95-year-old Elaine Creasey, who on Dec. 9, 2021, froze to death outside Keelson Harbour assisted living center in Spirit Lake. The second case involves 77-year-old Lynne Harriet Stewart, a former state social worker who froze to death on Jan. 21, 2022, outside Courtyard Estates at Hawthrone Crossing in Bondurant.
According to state records, Creasey wandered from her room at Keelson Harbour and exited the building shortly after 10 p.m. on Dec. 8, 2021. Because Creasey was known to wander, the staff was instructed to perform hourly, visual checks on her, and the exit door was equipped with an alarm to alert the staff in case someone left the building.
But, according to state records, the temp-agency worker who was assigned to check on Creasey during the night – identified in Board of Nursing records as registered nurse Brooke Arndt of Lake Park – repeatedly failed to confirm Arndt was in her room and didn’t investigate the cause of the door alarm.
With Creasey outside, a short distance from the exit door that had locked behind her, the temperature dropped to a wind chill of 14 degrees.
About 7 a.m. the next day, a worker went to Creasey’s room to check on her and noticed she was not in her apartment. A search was initiated and within a half-hour, employees found her unresponsive, lying on the ground outside the facility’s memory care unit.
The staff summoned an ambulance that transported Creasey to a nearby hospital where she was pronounced dead on arrival. The medical examiner later reported that his findings of hypothermia due to exposure were consistent with Creasey having exited the building about 10 p.m. the previous day.
Nurse: I wasn’t trained on bed checks
According to state inspectors, Arndt told investigators she had performed all of the required visual safety checks on Creasey between midnight and 5 a.m., although, she added, she had not been trained on how to perform such checks.
She reportedly told the inspectors that when she performed bed checks, she would open the door to a resident’s room, leave the light off, walk in a few steps and look for a silhouette of the resident in bed. She allegedly reported that she thought she had seen Creasey in bed each time she checked her room that night.
A review of the door-alarm system at Keelson Harbour allegedly showed the alarm had sounded at 10:07 p.m., indicating someone had exited the building, and was shut off and reset by the staff nine minutes later.
When interviewed, Arndt allegedly told inspectors that she had silenced the door alarm without checking on the residents or searching the area to see who might have left the building. Another worker at the home had told her not to worry about it, she said.
Arndt also stated she was not sure what the door alarm signified or what had triggered it, inspectors later reported, and alleged she had not received any training on emergencies and door alarms.
The state inspections department fined Keelson Harbour $10,000 for staff-training violations. Arndt was not criminally charged, but the Iowa Board of Nursing charged her with committing an act that “causes injury” to a patient and with failure to properly assess, evaluate or accurately document a patient’s status.
As part of a settlement agreement, the board placed Arndt’s license on one year of probation and required her to complete 30 hours of additional professional education.
Creasey’s family is now suing both Keelson Harbour and the temp agency that employed Arndt, accusing them of negligence and reckless disregard for another’s safety. The two companies deny any wrongdoing, and a trial is scheduled for Aug. 15, 2023.
The family has alleged Creasey’s hands and knees were covered in abrasions when she was found, indicating “that she had been crawling around in the cold outside for some time.” They say Creasey “suffered immensely, both physically and mentally, before she passed away.”
Video shows worker ‘walking around’ facility
A few weeks after Creasey died, 200 miles east of Spirit Lake, Lynne Stewart froze to death outside the Courtyard Estates assisted living center in Bondurant.
As with Creasey, Stewart was known to wander and was supposed to have been checked every hour.
State inspection records indicate a worker at the home — identified in court records as Catherine Forkpa, 31, of Ankeny — was assigned to check on Stewart throughout the night.
The center’s records showed that Stewart exited the building about 9:40 p.m., triggering an alarm. By that time, a separate alarm attached to the door of Stewart’s room had already been tripped. The two alarms triggered a series of alerts that appeared on a desktop computer used by the care facility’s staff, and on the portable devices carried by each of the workers.
But on the night in question, Forkpa was the only person working Stewart’s area of the building and surveillance video allegedly showed that instead of responding to the alarms, she “walked around” the memory-care unit for hours.
The temperature outside, meanwhile, was dropping and eventually dipped to 11 degrees below zero, state inspectors later reported.
For three hours of her shift, Forkpa was allegedly off-camera and unaccounted for, although police would later say the cameras trained on Stewart’s room showed that during her entire shift, Forkpa made no effort to enter Stewart’s room and check on her.
Executive director slept through phone alerts
At 5:30 a.m, the video showed Forkpa grabbing some breakfast for herself and walking to the dining room where she sat and ate. At 6:10 a.m., a worker who had been assigned to another area of the building looked at the nursing staff’s desktop computer and saw the door-alarm alerts for both Stewart’s room and the exit door at the end of Stewart’s hallway.
She immediately alerted Forkpa and the two quickly located Stewart outside, on the ground, with her body wedged against the exit door. An ambulance was summoned and paramedics rushed Stewart to a nearby hospital. Stewart, they later reported, was so stiff and cold they initially couldn’t record a body temperature. She had “ice freezing on her,” the paramedics reported, and there were abrasions on her head and hands.
Before the ambulance reached the hospital, Stewart went into cardiac arrest. Paramedic Tim Huff and his crew tried to restart her heart, but they were unsuccessful. Stewart was pronounced dead at the hospital.
Forkpa, who had worked at Courtyard Estates for seven months, was fired and four other employees were given written warnings for their failure to respond to the door alarms, according to state records.
During the subsequent state investigation, the facility’s executive director told inspectors that when she is at home, she receives text-message alerts when doors alarms are triggered at the facility. She said that on the night in question, she received a long series of alerts triggered by the two door alarms, but she didn’t hear them as she slept.
Screenshots of the executive director’s phone indicate she received the first alert on her phone at 9:44 p.m., and continued to receive them every five minutes throughout the night, inspectors alleged.
The facility’s on-call registered nurse received a similar series of alerts on her phone. She allegedly told inspectors she had noticed the recurring alerts but failed to respond to them because she was at home with her family, and because she went to bed around 9:30 p.m.
The nurse reportedly told inspectors that in the past, she had ignored alerts that were specific to Stewart’s room because of mechanical defects that caused that particular alarm to trigger constantly. Other employees, including Forkpa, reported the same problem to inspectors.
Caregiver charged with murder
The state fined Couryard Estates $10,000 and cited it for having failed to give Forkpa the required 8 hours of dementia training during her first month on the job, instead giving her only 4.75 hours of training. Courtyard Estates acknowledged the problem and later reported to the state that the training issue was corrected by having Forkpa fired.
Forkpa now faces a charge of second-degree murder by dependent adult abuse. If convicted on that charge, she faces a term of imprisonment not to exceed 50 years and would have to serve 35 years before becoming eligible for parole.
Forkpa, who immigrated to the United States from Africa in 2004, said she doesn’t believe the criminal charge is warranted. “I know in my heart I would never do anything to hurt anyone,” she told the Iowa Capital Dispatch.
Polk County Attorney John Sarcone declined to comment on the case. A trial is scheduled for Nov. 14.
Police reports indicate that even before Stewart exited the building that night, there were signs, unnoticed by the staff, she was preparing to leave.
According to the police, Stewart appeared to have spent some time collecting her clothing and other belongings and carrying them down the hallway to the exit. She set a bag of personal items next to the door and draped some clothes over a nearby railing before walking out into the cold night air, with the door locking behind her.
She had done this sort of thing in the past, according to state inspectors, telling the staff at Courtyard Estates that she was packing up her things and “going home.”
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