Family members of residents in the Mississippi State Veterans Home in Oxford say they’re “not surprised” by the recent manslaughter charges brought against two former aides for the death of 93-year-old World War II veteran Durley Bratton.

The surprising thing, one resident’s wife said, is that more people aren’t held accountable for injuries and neglect of other residents. Kay Kinsella, whose husband lived in the home for two years before passing away, described one incident when her husband received a mysterious bruise. The cause of the bruise, she said, was never disclosed to her.

At the time of the injury, Kinsella’s husband, Tom, was non-verbal and on hospice care. He also suffered from dementia and muscular dystrophy and had no mobility in his arms or legs.

Kinsella said she called an employee who was there when the incident happened, and was told it was “no big deal.” After being initially told that Tom had hit his head, the employee denied it and said that the staff didn’t know where the bruise came from. After that, Kinsella was told the lift that was used to move her husband from his bed to his wheelchair started failing, and the aides had to “sling him into his chair.”

“I asked to see an incident report about it, and [the administration] told me it wasn’t part of his medical records and I did not have access to it,” she said. “But I had an aide tell me she was standing at the desk when it happened and was looking down the hallway. The aides came out and said, ‘Get the supervising nurse – Kinsella is on the floor.’ She said she didn’t see him personally, but that’s what happened.”

The aide, she said, was reprimanded for revealing that information. After the administrative investigation was complete, Kinsella said she was still not privy to any information.

“I kept saying to them, ‘If you dropped him, just say so and we’ll make it a learning experience.’ I just wanted to know the truth. I feared for my husband’s safety,” she said. “I don’t think that had anything to do with Tom’s death, but I think it contributes to them not training their employees properly and then not making them be accountable.”

James Garner, chairman of the state Veterans Affairs Board, said every report the VAB receives is thoroughly investigated. The policies and procedures for handling such incidents, he said, are followed in Oxford just as they would be in the state’s other three veterans homes.

“If there is an incident, if something happens, the person who’s giving the care will report it to the head nurse,” Garner said. “Then one of our people from the state office will investigate it. Nothing goes unreported that should be reported.”

The main advocacy group for the residents is the family council. Jody Carpenter, whose husband Brinson has been a resident since November 2015, is the group’s secretary. Carpenter said she’s seen a troubling behavior pattern in the way many aides treat residents – especially those who can’t speak for themselves.

Brinson  is in the late stages of dementia, and as such has lost his mobility and speech.

Carpenter said she spends approximately six hours per day during the week, and 11 hours a day on weekends, with her husband in the veterans home. While she’s lucky enough to spend a majority of her time with her husband, she admitted concern for other residents who don’t have a loved one attending to them.

While there are areas of inadequacy in other units, none are as prevalent as B-Wing, the home’s secured unit, she said.

“I’ve been down there before, and the way they talked to these guys and treated them, was awful,” Carpenter said. “I’ve seen them drag guys down the hallway, I’ve seen them holler at them, talk disrespectfully to them. It was ridiculous, and all I could think was, what are they doing when I’m not here?”

Although the majority of residents have Alzheimer’s and dementia, B-Wing is not specifically designated for that purpose. This is problematic, Carpenter said, because the residents are missing out on specialized care and services they need – ones they’d receive in a memory care unit.

Joe Dickey, whose father has been in the veterans home for four years, has spent three years as president of the family council. Dickey’s father lives in B-Wing, and he said he spends at least three hours per day there with him. While many aides perform their jobs well and treat the residents with dignity, he said, others exhibit alarming behavior.

Dickey, a veteran himself, said he takes his role as an advocate for his father and other residents very seriously. However, he said, the reports he’s made to veterans home administrators have yielded little change.

“The family council has always been aware of and has reported multiple issues involving resident care and treatment of residents,” Dickey said. “We have also asked for better treatment of those with Alzheimer’s and dementia and asked for staff training in this area. There has been no improvement that we can see in staff training. The administrator has told us that the unit that houses Alzheimer’s and dementia residents is not an Alzheimer’s and dementia unit, so they do not have to meet those standards.”

Dickey, at times, reported issues directly to Randy Reeves, the former Executive Director of Veterans Affairs for Mississippi who was recently appointed by President Donald Trump as the Under Secretary of Memorial Affairs.

After Dickey reported resident concerns discussed during joint veterans organization meetings held in May and October 2017, Reeves issued the following response:

“Rest assured, each of these [issues] is being looked into,” Reeves said via email. “When I receive any report that may involve the care or dignity (especially) of residents, we first investigate.”

However, Dickey, Kinsella and Carpenter said they’ve seen little change in the 10 months since the email. The only thing they can vouch for, Carpenter said, is the cleanliness of the facility.

Recently, Dickey, along with other family members, a resident and a volunteer, cited an example of a man who died in the last month after his sockless, shoeless foot was accidentally run over by a wheelchair. Due to improper care, Dickey said, the man contracted gangrene and died when the infection spread throughout his body.

Family members of residents aren’t the only people who say they’ve noticed issues. Lauren Graham, an Ole Miss student who volunteers at the veterans home, said she’s had several heartbreaking encounters with residents who expressed emotional distress.

“When I was in there I spoke with a man who was a police officer his whole life. He looked at me and said, ‘I’ve put criminals in prison my entire life.’ Then, he looked at the floor and said, ‘I never thought I’d end up in prison myself.’ It was everything I could do not to cry,” Graham said. “That’s just one of the people who can talk and speak up for themselves.”

According to recorded minutes from family council meetings, which are submitted to the veterans home administration and to the state VAB, family members often complain that they arrive in the mornings to find their loved ones saturated in urine. If their adult diapers are changed, Maxine Brown, a resident’s wife, said, there’s a strong possibility the person who changed them did not do so adequately and left fecal matter or urine behind.

Brown, whose husband had a stroke, said even though she had made sure the staff was aware of her husband’s risk for seizures and aspiration, she’d walked in his room more than once to find him eating breakfast alone with no one to monitor his safety.

“When I walked in and found him alone with his breakfast, the aid was down the hall distributing food to other residents. I spoke to her along with the head nurse and social worker about it,” Brown said. “More than likely, she was probably the only one on the hall who was trying to feed all these people. What I think is, she probably left and was going to come right back, but in a fraction of a second, he could’ve aspirated and died.”

The issue, Brown said, might not have been the quality of work done, but the amount of staff willing to do it. Administratively, she said, something needs to be done.

“We constantly hear that they’re understaffed, that ‘We’re short today, so we’re having trouble getting this or that done.’ When it comes to my husband’s care, I tell them, that is an administrative issue,” she said. “There are people all over the place when the Big Wigs are coming to visit. Why can’t they do that on a normal, everyday basis?”

Brown said when serious issues are addressed, things may change for a while before backsliding.

Overall, the family members, volunteers and residents said the biggest problems were an apparent lack of training for hourly workers and the use of cell phones. According to the cell phone policy set forth by the Mississippi State Veterans Home – Oxford, employees on the clock are “strictly prohibited” from taking personal calls, texts, checking Facebook, et cetera, and phones should never be visible in work areas.

However, Carpenter said she finds the policy laughable, because of the high volume of employees using their phones while at work.

“Cell phones are the biggest problem. They’ll be sitting there in the common area, two or three aides at the time, and they’ll be punching on their phones,” Carpenter said. “ I think it’s poor leadership. We asked about the phone policy and were told, ‘Yeah, we try.’ No. You shouldn’t just try – you should do. These guys depend on you to be their leader and their advocate.”

If an employee does exhibit exemplary care for residents, Carpenter said they are often let go. One former employee who found himself in a precarious situation is Vietnam veteran Joe Singletary. Singletary spent nearly five years in the activities department of the veterans home, where his job was to help veterans go to and from scheduled activities, including chapel and music time.

Often, Singletary said, he would go to B-Wing and find residents walking without socks and shoes on and in ill-fitting clothes. He said he would take it upon himself to fix these situations, because the aides were often otherwise occupied.

Carpenter and Kinsella both praised Singletary, and said he went above and beyond to improve the quality of life for the veterans. He said he particularly liked to spend time with residents who didn’t have regular visitors.

His outstanding performance was even recognized by the state VAB, who named him the 2016 Employee of the Year for Mississippi. It’s one of Singletary’s many awards, which he still holds on to even after his employment was terminated.

“I think I might have intimidated some of the workers by doing everything that I did, because it kind of made them look bad,” Singletary said. “But like I told them, we’re there for the veterans’ benefit. If it wasn’t for them, we wouldn’t be there, so as far as I’m concerned, the veterans are our boss, so we need to listen to them.”

Because it was a scheduled activity, Singletary said he took 20 residents to a joint veterans organization meeting on Oct. 7, 2017. At the meeting, the residents expressed what he later called “damaging information” about their experience in the veterans home, which he reported to the administration.

A prepared statement he was asked to make read: “… As I see it, this is where a lot of our bad reputation is coming from, which, in a way, might help things to be improved, if that’s what our goal is.”

Singletary said an administrator at the veterans home was displeased with that sentence, and after he refused to remove it from the statement, trouble began.

On Oct. 27, 2017, Singletary was accused of inappropriately touching a resident. He was later cleared of the charge, but not before his employment was terminated. He said he is now barred from entering the veterans home and visiting the residents he’d come to know as friends.

“My only goal was to help the veterans. As a veteran, I hope to see the care of the place improved,” Singletary said. “(The administration) does a great job, the place is spotless and beautiful. It can look like heaven, but if the care is not proper, what have you accomplished? I don’t want to come after anyone; I just want the truth to be known.”

It’s not all bad, as one resident, who wished to remain anonymous, stated. The facility and grounds are one bright spot, he said, but residents who have concerns have venues in which they can express them.

“We have a resident council we can go to that is attended by an administrator, and they can voice their concerns in there,” he said. “I’d say about 50 percent of the concerns are resolved. I try to be fair to both us and the administrators, because they do have a rough job.”

Repeated requests for comment from the veterans home were unanswered by deadline. However, veterans home administrator Amanda May issued the following statement to the EAGLE regarding the death of Durley Bratton at the hands of two aides.

“The care of our veterans at all of our nursing homes is our upmost (sic) priority,” May said. “We have been cooperating with law enforcement officials during the investigation, but due to the nature we cannot comment on this ongoing investigation.”