A Long Term Care Nightmare – Part I

Introduction and a Human Story- 

ABC News reported that Sal and Mabel Mangano were helpless at the moment as they watched St. Rita’s nursing facility filled with water.

On August 29, 2005, the staff and residents of St. Rita’s heard rumbling and saw a wall of water approaching their facility. I’m sure they must’ve felt like the Captain in the Poseidon Adventure movie.

Although Sal and Mabel made the fateful decision to shelter in place versus evacuate and would rescue 52 others, 34 drowned in their beds or wheelchairs during a period of 20 to 30 minutes with water flowing to the ceiling. Reports vary as to whether there were 34 or 35 victims.

Three months later, it was reported that an unidentified person was located a month later behind Sal Jr’s home, deceased with a feeding tube still attached. 

The human toll can be measured in many ways: statistics on a page, body counts, number of funerals, persons unaccounted for, and the story of one family to cast a light in which emotions take center stage. 

Tufanio Gallodoro’s family decided to finally get him the hell out of harm’s way in St. Bernard’s Parish, New Orleans in 2004, to escape the possible devastation of Hurricane Ivan. As reported in Esquire, his daughter Cheryl had taken on the decision this time. His son Steve was a local firefighter and had many emergency management duties in the town. Their ultimate destination was Tennessee. However, after a 16-hour drive, Tufanio became severely compromised, could not sit upright when they arrived in Jackson, Mississippi. As Steve related, his father was 82, had two previous strokes, and was confined to a wheelchair. During their trip, the kindness of a stranger prevailed, where he offered to have Cheryl and Tufanio stay with his family in a large home. 

That trip was the deciding moment, in that they realized they could no longer care for him without help. Even with in-home assistance, Tufanio needed skilled care. Therefore, they decided among the four facilities in St. Bernard Parish, with the closest being a family-run facility known as St. Rita’s. (FYI, St. Rita’s saintly status is attributed to “Lost and Impossibe Causes.” Steve thought they had done their due diligence and adequately checked out the facility and the Manganos.

A year before Katrina arrived, all had seemed in order-The Manganos were in business for 22 years, on a 20-acre property, with Sal Jr. “Little Sal” as the maintenance man. He and his parents practically lived at St. Rita’s night and day. But, it was also reported, Mabel, with her big white hairdo, was very nurturing, doted on those without visitors, carried change for all to buy them sundries, and even taught one woman to drive a car up and down their driveway. 

Steve and his family helped serve as an essential caregiver, often visiting to feed him, shaving him, and cutting his hair with St Rita’s nearly open door policy.

The Saturday before the hurricane, Steve knew the storm was coming. 

He also knew that his father nearly died from transfer trauma-(multiple stresses on the resident which ultimately accelerates their death due to being moved from one facility to another.)  

He could not personally remove him because of his firefighting duties.

In Steve’s words,

 “The Manganos assured me they’d contracted with bus services, they had staff coming in, they had two facilities to transport the residents to if the call for evacuation was made. They said, “We are the professionals, leave him with us. He’s better off. “My sister had some emotional struggles about leaving him, but I told her the Manganos had a plan in place. Let’s leave him with them.

Early Sunday morning, after the rest of his family safely evacuated, Steve approached Sal Mangano and offered whatever the number of men needed to evacuate. He was dumbfounded when he learned that they had chosen to ride it out as they had done so many times in the past. Nevertheless, Steve was concerned, and the coroner, Dr. Bryan Bertucci, called the Manganos to recommend (although not stated as an order) that they should leave and offered two school buses to take them to any destination they would like. Mabel declined.

As the storm progressed, Steve kept very busy rescuing anyone he encountered from rooftops, trees, etc. But, unfortunately, he relied on inaccurate weather reports at St. Rita’s location and on the fact that he would have received word if the situation was grave. How wrong he was! 

Other sources reported that by Tuesday, Mabel changed her mind and called two hours later and asked for buses, but it was much too little too late.

What Steve saw from his boat was a nightmare. Finally, here was an experienced firefighter who could not save his father! But, life is full of ironies. 

 “Tufanio Gallodoro couldn’t swim. Tufanio Gallodoro was deathly afraid of the water. Tufanio Gallodoro drowned. For his son, the horror of St. Rita’s will always be a moral horror, and he will never stop holding the Manganos morally responsible.” According to a report by CBS News, on January 31, 2008, 

 “The reality sunk in for a vast majority of our residents Friday and Saturday. That made them pack up and go.”

That Saturday night, Steve’s sister Cheryl was checking in on her father one last time at St. Rita’s before taking her family north. 

My dad looked up and called me ‘Shay.’ That was a little pet name he had for me. And said, ‘Shay, you coming to get me tomorrow? They have a hurricane coming,‘” she remembers. “I looked at him, and I said, ‘Well, dad, you know. You’re going to be taken care of.” Cheryl knew it was too risky to move her frail father herself, so she was relying on St. Rita’s to take him out of harm’s way. He continued to ask.

As Cheryl recounted, a nurse came in and sat close to her, taking her hands in hers. Then, the nurse advised that Cheryl needed to leave. 

She assured her that there was an evacuation plan and that Tufanio would be well cared for.

By 8:00 a.m on Sunday, August 28, parish officials broadcast their starkest warning yet to those who might still be in the parish. “You need to leave. You must leave St. Bernard Parish and head north,” they warned.

Before Sunday, Polly Boudreaux, the Parish clerk, said St. Bernard officials were desperately telling residents to leave. “There were messages over and over, not just parish government messages on our cable station, but the news media was out saying the same thing,” she said.

Larry Ingargiola was the director of Homeland Security for St. Bernard Parish. “I believed that we were gonna see 20, 22 feet of water.”

In hindsight, as a more objective reader, would it not make sense to err on the side of caution even though historically, other hurricanes did not rise to the level of Katrina? To rely on history and what you’ve always done was indeed a fatal error in judgment!

Sal and Mabel Mangano-

Sal and Mabel were of Italian descent and very nurturing by nature. They met 45 years earlier and quickly fell in love. Sal was a manual jack of all trades and could fix anything, preferring such labor to academics where he quit school.

Their introduction to business was a successful feed and seed store enterprise. Mabel became increasingly dissatisfied with the treatment of her grandmother in a nursing home in the 1970s, in which the quality of life was non-existent. Mabel vowed that if she opened such a business, no one would ever suffer as her grandmother had. It was dark, dank, with awful food and no activities whatsoever. It was indeed God’s waiting room, as a social worker friend of mine used to say. 

Earlier family generations were public service-oriented. Mabel’s father was a fisherman turned deputy sheriff; others included the Captain of the parish fire department and a trusted family friend who rose in the ranks from Attorney to DA. 

Their immediate family consisted of Sal Jr, known as “Little Sal,” and Tammy, who had two children, Sal III, a police officer, Tanner, a high-ranking former Marine, and Tammy’s son, Johnny White.  

Sal was a husky man with an olive complexion and strong hands. Mabel was also somewhat imposing with her curly white hairstyle coiffured in a 50’s style, making her presence known. 

In the 20-25 years I have professionally worked in geriatric settings, I have worked with every race, ethnicity, and personality from Administrator to CNA to custodian and found some gems at all levels who truly owned their job.

Sal and Mabel reportedly weren’t formally educated, nor were they sophisticated. Instead, they appeared to lead with their hearts and what seemed right to them. They had managed St. Rita’s Home (named after Mabel’s Grandmother) for 20 years. Mable got assistance applying to the State of Louisiana to meet all of a business owner’s requirements and apply for a Certificate of Need Persevering. She went to school and trained to be a Nursing Home Administrator, with a sea of paperwork, and achieved her goal after about eight years and hundreds of trips back and forth to New Orleans despite naysayers.

The Manganos chose a tract of land that was four to six feet above sea level, which was enough to keep them dry and safe in previous storms but wholly inadequate for Katrina.

Fast forward to today, and we learn that be a Nursing Home Administrator must oversee all operations at nursing home facilities, including both clinical and administrative tasks. These tasks include dealing with budgetary issues, marketing, patient care, and staff management. They must gain funding and manage the facility’s budget to afford to pay qualified staff, obtain any medical equipment they need, and pay for advertisement. Additionally, they ensure federal, and state safety standards are in place so their clients can live healthy and pain-free lives. Nursing home administrators also represent their facility at board or investor meetings. In addition to their administrative duties, NHAs manage the staff members at their facility, including caretakers, nurses, and administrative assistants. They set work schedules, carry out performance reviews, and make sure employees follow best practices for patient care. Most states require at least a bachelor’s degree for licensure it requires.

  • Step 1: Create a business plan; 
  • Step 2: Register with the state: 
  • Step 3: Obtain Medicare and Medicaid certifications: 
  • Step 4: Hire a great staff; 
  • Step 5: Recruit your clients; 
  • Step 6: Have a solid financing plan for growth.

The vast majority of skilled nursing homes are now owned by large corporate management companies with many sites regionally or nationally that can assist with training and often hire a separate Rehabilitation staffing company for therapy services. 

Mabel and Sal began their usual preparations for the hurricane season on June 1. The season is typically June through November, with the majority of activity occurring in August and the first half of September. 

They stocked up on emergency food, medicine, and other supplies. Sal had bought new gas generators to run washers and dryers to wash clothes rather than filling up their vehicles like everyone else to vacate.

In essence, they did everything a good Grandma & Grandpa would do based upon the cultural needs and former hurricane history in the past. Their preparation had always worked in the past, so why not with Katrina? But, one size does not fit all.

During a January post- Katrina interview with CBS News’ Harold Dow, Mabel was circumspect in her comments about the tragedy, but the most hurtful thing was that her former friends had spoken badly and testified against her. To her, they were saying, “a terrible mistake equated to her being a bad person.” I think she had to put her emotions first versus the lives lost. Otherwise, how could she sleep or carry on for the future? Even on a moral level, she seemed to distance herself from taking any responsibility. Video, 2 min, 45 sec. https://www.cbsnews.com/news/no-way-out-31-01-2008/ ;

Many people have made tragic mistakes. Perhaps the difference here is that those who do not benefit from education and a more worldly view could only see their picture and not the colossal big picture unfolding. “What we’ve always done” is not proactive thinking when you are responsible for the lives of frail residents, some of their family members, and your staff (who may or may not be your own family.)

Timeline- 

  1. St. Bernard Parish, Louisiana, lies to the East of New Orleans and thus was closer to the path of the storm and more exposed to the storm surge from the Gulf of Mexico. St Bernard’s Parish was completely flooded via water surging into Lake Borgne.
  2.  A large portion of the flooding resulted from levee failures along the Mississippi River – Gulf Outlet Canal, a 76 miles (122 km) canal. 
  3. The parish levees were built to hold back up to 17.5 feet (5.3 m)of water; although they held back the initial surge, they were then breached in several areas by the 22 feet (6.7 m)surge.

The parish’s two shelters at Chalmette High School and St. Bernard High School suffered considerable damage with flooding. Chalmette High lost much of its roof, and St. Bernard High had many broken windows. There were estimates of 300-plus evacuees at both sites.

By August 29, about 150 people were stranded on rooftops in areas that were under approximately 8–10 feet or more of water. Among those on the roofs were WDSU reporter Heath Allen and a St. Bernard resident on a government complex rooftop. Residents reported that even oil platform service boats were utilized to rescue survivors.

Was it a Train or a Six Foot Wall of Water?

The levee breaches and overtopping resulted in 15 to 20 feet floodwaters, covering about 80 percent of the city. The catastrophic damage and loss of life inflicted by this hurricane is staggering, with an estimated 1,353 direct fatalities1 and 275,000 homes damaged or destroyed. According to the American Insurance Services Group, Katrina caused an estimated $40.6 billion in insured losses (as of June 2006). The National Hurricane Center typically doubles the estimated insured losses to calculate total damage losses in the U.S., giving an estimated $81.2 billion in damage. Thus, total economic losses could be greater than $100 billion. These impacts make Katrina the costliest hurricane in U.S. history and one of the five deadliest hurricanes ever to strike the U.S.

On Friday, August 26, the Weather Forecast Office – New Orleans/Baton Rouge contacted emergency managers in southeast Louisiana and coastal Mississippi to advise them to monitor Katrina. While they explained the uncertainty inherent in two and three-day tropical cyclone forecasts, they noted the westward computer model trends and that Katrina could be a major hurricane at landfall – Category 3 or 4. They told them to prepare for potential hurricane watches and warnings the following day. Later in the afternoon of August 26, the Southeast Louisiana Hurricane Taskforce held its first conference call. 

The final significant adjustment to the National Hurricane forecast occurred in the 10 p.m. CDT, August 26 advisory, 56 hours before landfall. The hurricane’s track was adjusted farther west, projecting landfall in southeast Louisiana and a second landfall near the Louisiana/Mississippi border. The intensity forecast projected Katrina as a major hurricane until final landfall. The forecast discussion noted an above-average level of confidence in the prediction.

At 11 a.m. EDT on Saturday, August 27, NHC issued a hurricane watch from Morgan City, Louisiana, to the mouth of the Pearl River (Louisiana-Mississippi border), including metropolitan New Orleans. Later that afternoon, and extended the hurricane watch eastward across southern Mississippi to the Alabama-Florida border. On August 27, the hurricane watch was upgraded to a warning, and the intensity forecast called for Katrina to be a major hurricane at landfall.

NHC introduced storm surge forecasts for southeast Louisiana and coastal Mississippi in the 11 p.m. EDT. August 27 forecasts may be as high as 25 feet.– 32 hours before Katrina’s landfall in southeast Louisiana. 

On Sunday morning, August 28, 10 tornado watches were issued in the south and the east-central United States as Katrina moved inland. Sixty-one tornadoes occurred from August 28 to August 30 from Mississippi to Pennsylvania.

The same Weather Office: New Orleans/Baton Rouge stated, “catastrophic hurricane expected” and urged residents to rush all protective measures to completion. At 10:11 a.m., August 28, the updated statement emphasized the horrific impacts Katrina would likely create for southeast Louisiana and coastal Mississippi. 

URGENT – WEATHER MESSAGE

NATIONAL WEATHER SERVICE NEW ORLEANS LA 1011 A.M. CDT SUN AUG 28 2005

DEVASTATING DAMAGE EXPECTED…

.HURRICANE KATRINA…A MOST POWERFUL HURRICANE WITH UNPRECEDENTED STRENGTH…RIVALING THE INTENSITY OF HURRICANE CAMILLE OF 1969.

MOST OF THE AREA WILL BE UNINHABITABLE FOR WEEKS…PERHAPS LONGER. AT LEAST ONE HALF OF WELL CONSTRUCTED HOMES WILL HAVE ROOF AND WALL FAILURE. ALL GABLED ROOFS WILL FAIL…LEAVING THOSE HOMES SEVERELY DAMAGED OR DESTROYED.

THE MAJORITY OF INDUSTRIAL BUILDINGS WILL BECOME NON FUNCTIONAL. PARTIAL TO COMPLETE WALL AND ROOF FAILURE IS EXPECTED. ALL WOOD FRAMED LOW RISING APARTMENT BUILDINGS WILL BE DESTROYED. CONCRETE BLOCK LOW RISE APARTMENTS WILL SUSTAIN MAJOR DAMAGE…INCLUDING SOME WALL AND ROOF FAILURE.

HIGH RISE OFFICE AND APARTMENT BUILDINGS WILL SWAY DANGEROUSLY…A FEW TO THE POINT OF TOTAL COLLAPSE. ALL WINDOWS WILL BLOW OUT.

AIRBORNE DEBRIS WILL BE WIDESPREAD…AND MAY INCLUDE HEAVY ITEMS SUCH AS HOUSEHOLD APPLIANCES AND EVEN LIGHT VEHICLES. SPORT UTILITY VEHICLES AND LIGHT TRUCKS WILL BE MOVED. THE BLOWN DEBRIS WILL CREATE ADDITIONAL DESTRUCTION. PERSONS…PETS…AND LIVESTOCK EXPOSED TO THE WINDS WILL FACE CERTAIN DEATH IF STRUCK.

POWER OUTAGES WILL LAST FOR WEEKS…AS MOST POWER POLES WILL BE DOWN AND TRANSFORMERS DESTROYED. WATER SHORTAGES WILL MAKE HUMAN SUFFERING INCREDIBLE BY MODERN STANDARDS.

THE VAST MAJORITY OF NATIVE TREES WILL BE SNAPPED OR UPROOTED. ONLY THE HEARTIEST WILL REMAIN STANDING…BUT BE TOTALLY DEFOLIATED. FEW CROPS WILL REMAIN. LIVESTOCK LEFT EXPOSED TO THE WINDS WILL BE KILLED.

AN INLAND HURRICANE WIND WARNING IS ISSUED WHEN SUSTAINED WINDS NEAR HURRICANE-FORCE…OR FREQUENT GUSTS AT OR ABOVE HURRICANE FORCE…ARE CERTAIN WITHIN THE NEXT 12 TO 24 HOURS.

ONCE TROPICAL STORM AND HURRICANE-FORCE WINDS ONSET…DO NOT VENTURE OUTSIDE!

Could anything have been more clear as to the danger?

Fatal Flaws –

What were the many fatal mistakes that may have contributed to this mass drowning?

  •  35 Charges of Negligent Homicide by the Louisiana AG- Charles C. Foti, Jr- As defined, Mabel and Sal “demonstrated such a disregard of the interest of others that the offenders’ conduct amounted to a gross deviation below the standard of care to be maintained by reasonably careful people.” This negligence was the prosecutors’ job to prove.
  •  On Sunday, August 28, according to a news release from the Louisiana State Patrol, they categorized Katrina as a mandatory evacuation. However, St. Bernard Parish reportedly didn’t make an official statement on Saturday, August 27, because they would not be offering shelters. 
  • Mabel reported that “they would be notified and weren’t.

In 20 previous years worth of storms, they had never evacuated nor lost a life. 

  • Their nursing home was located on a patch of land on a higher elevation and hadn’t flooded in the past; 
  • They had an emergency plan that was on file, and they had done their usual preparations with residents and staff; 
  • The standard operating procedure – evacuation plans for all nursing homes in the state was to initiate the schedule 72 hours before a hurricane makes landfall; 
  • The St. Rita’s filed plan specifically stated that “they were to evacuate 48 hours before a Category 3 storm or larger.”
  • All other nursing homes in the geographic area of St. Rita’s Home evacuated accept them;
  • Mabel was concerned for the special needs patients who may not withstand a bus ride (as others had died in other geographic locations);
  • Sal bought extra generators and gas to run the laundry facilities to “shelter in place” for the duration versus getting gas to evacuate;
  • They had prepared meals ahead of time in anticipation of staying;
  • The County Medical Examiner, Dr. Bryan Bertucci, recommended they evacuate and offered two buses and two drivers for all 70 residents to wherever they wanted to go; Mabel refused the offer, and then she called again two hours later. But it was too late; He testified that it wasn’t his job to order or demand but strongly recommend.  
  • The Manganos declined extra firefighters – emergency management staff when Steve Galodoro (whose father resided at St Rita’s) offered, because “they had a plan and more nursing staff was coming”;
  • Defense Atty Jim Cobb interviewed Director of Nursing, Diane C. He asked, “But why were you still there? Who was watching the weather? Didn’t you see how bad they were saying Katrina was going to be? “She replied, “I was. I watched the weather on TV so much they called me Bob Breck.” (local meteorologist.) “Everyone knew how bad they were predicting it would be. Sal and Mabel knew it too. So you couldn’t miss it.” 
  • Diane C. told Defense Atty Jim Cobb when asked, “Tell me about the decision-making process you all used to determine whether you were going to stay or evacuate. How did that work?”  
  • Don replied, “There wasn’t no process. Sal and Mabel were the owners, and Mabel was the Administrator. It was her call. You know, I’d been there for years, and we never, ever evacuated before, and everything turned out fine. ‘Just this time…. I shouldn’t even be here.” (referring to how she nearly died) p. 125 (Flood of Lies);
  • Louisiana AG Foti repeatedly stated to the media that Sal and Mabel had ignored a mandatory evacuation from the St. Bernard Parish Government. In contrast, New Orleans Governor Kathleen Blanco and Mayor Nagin had issued the evacuation mandate for New Orleans on Sunday morning, August 28. (Knowing that Bernard Parish is lower in elevation, was closer to the coast, and surrounded by water on almost all sides, it would stand to reason that Mabel should have known the danger. (p. 49);
  • At 6 a.m. on Sunday, August 28, Mabel was intent on feeding her residents, staff and family members a hot breakfast, including hand feeding many residents despite winds over 100 mph and loss of power from the regular generator. Sal also began preparing lunch as culturally, all things revolved around food for Louisiana residents. It appeared that they were oblivious to the dire situation until “the wall of water that sounded like an oncoming train” abruptly struck on Monday morning.

GOVERNMENT RULES-

There are layers of bureaucracy that dictate what nursing facilities can and cannot do, including Federal Guidelines, State Statutes, County and City policies, and more. 

One of the most glaring tragedies of Hurricane Katrina has to be whether the existing evacuation and nursing safety procedures were adequate at the time? The very learned advice of Attorney and Professor Robert Mead from the University of Kansas Law school says, NO. I won’t belabor the reader with lots of legal gibberish. But, some points are worth sharing –  

  • Federal regulations by nature are broad and vague, necessitating SNFs to develop their plans; It is incredulous that these Federal Regs do not explicitly require that nursing homes follow their plans, “only that they have a plan on file.”
  • The Federal and state legislatures historically have failed to hold nursing homes to a higher standard due to the power of nursing home lobbyists;
  • There need to be alternatives to strengthen torts- acts of injury or harm to others resulting in civil suits and criminal lawsuits.
  • Attorney Mead recommends that strengthening Federal Regulations is the “superior path to take,” as well as threatening to withhold Medicare and Medicaid funds. Other penalties do not sufficiently motivate change;
  • For nursing homes to receive Medicare and Medicaid funds, the Feds require the highest standard of care and need to comply with all Federal and State codes.
  • Emergency preparedness must include detailed plans and procedures, training, and drills. BUT, unannounced drills should not upset residents. The vital measure of how effective they indeed also appear absent.
  • Following Katrina, there were tricky ways in which legislators manipulated legislation and policy to exempt current nursing homes and hospital buildings and building codes from improvement, limiting them to newly built facilities;
  • A Catch 22 exists with the evacuation of nursing home residents in an emergency. Compromised residents will likely die from transfer trauma or the actual event itself or in the aftermath months later. Such was the dilemma of Sal and Mabel Mangano.
  • Other thorny matters- Did liability exist because of negligence by the nursing home or a resident’s underlying medical condition? Was it an Act of God? (i.e., Was the threat foreseeable? Were the defendants’ precautions reasonable and met a good standard of care?
  • CMS – The Center for Medicare & Medicaid Services are not the police for nursing homes. Their purpose is to qualify providers for Medicare and Medicaid Programs. They cannot hold medical directors responsible.  

Coming in Part II-

  • Lessons from the Defense, James J. Cobb, Jr; Author of “Flood of Lies;
  • After Katrina – What Should Have been a Happy Ending;
  • And then the Final Ending.

One comment

  1. dearest donna thank you for sharing this horrific story- many lessons to be learned for every one of us-valuable lessons. most difficult to feel so bad for the residents and their families and hols so much sorrow for the brave couple who made an error in judgement…When you receive part 2 we all be so very grateful for your sharing. huge love gratitude and respect is yours dear Lady Justice!gretchen

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