Janus Kayman McCrea 2314 Desota Drive Ft. Lauderdale, FL 33301 December Mr. Alfred Cortes, Mgr.

Customer Services PCA of Florida 301 Yamato Rd. , # 4200 Boca Raton FL 33431 Dr. Greg Cohn Cleveland Clinic 300 W. Cypress Crk Rd. Ft. Lauderdale, FL 33309

23, 1996

TO WHOM IT MAY CONCERN RE: Complaint/Concern About Medical and Rehab Center Treatment for Esther Aronin. Aronin underwent surgery for a hip replacement. Prior to and the operation went well. From Oct. 24 until Nov. 7, care of Heartland of Tamarac, a center for recuperative Cleveland Clinic/PCA medical coverage.

On October 17, 1996 Esther that her lab tests were good Esther Aronin was under the therapy that was part of the

The focus of this letter is on the level of attention given to Esther Aronin, particularly leading to a failure of the staff or Mrs. Aronin's assigned medical professionals to diagnose a problem that worsened her condition and resulted in her becoming very ill (possibly a pancreas problem, but to date none of Mrs. Aronin's caretakers have stated a diagnosis based on the lab results or symptoms of her illness). The core problem appears to be: arrived, and B) no physician could either Mrs. Aronin's or her family's response we incurred. To simplify A) No blood work was ordered for Esther when she be convinced to respond within a resonable time to concerns. All we can do is relate events, and the things, events will be numbered.

1. Mrs. Aronin arrived at Heartland on Thursday, Oct. 24. When I visited her that evening she complained about pain and nausea, and could not eat. We asked about speaking with a doctor, and were told Dr. Sood would be there Friday morning. We asked for painkillers - Mrs. Aronin had arrived at noon and by 4: 15 p.m. had not received any pain relief. I then tried to contact Dr. Gregory Cohn. I could not reach the doctor personally and was informed by his staff that from this point on Dr. Sood was Mrs. Aronin's primary physician and that Dr. Cohn's office was no longer involved. When I called at 9: 15 p.m., Mrs. Aronin was still waiting and in considerable pain. She only received medication after I called the front desk and announced I was coming over right then. It took nine hours to get her a painkiller.
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Although I wanted to speak with the doctor there, I was told she could not be reached but would be there later. Mrs. Aronin said on Friday that the doctor stopped by, but that Dr. Sood did not stay or have a long conversation with her. We never did reach a principal medical person at Heartland. When we kept asking, we were given a "mediation number," a Ms. "Tammy Soffer" at 978-5207. As I recall, there was a tape machine at this number. No one from Heartland or PCA ever returned our call. 2. On Saturday afternoon, October 26, I was told by one of the staff that "Dr. Sood was very upset with me for making her look bad." Although I wanted to make a stronger attempt to speak with Dr. Sood regarding Mrs. Aronin's nausea and medication, Mrs. Aronin was very upset and said the staff would "punish" her if we made any more trouble and asked that we wait for Dr. Sood to return. (We will cover this later.) * * 3. When Esther said that she could not eat and that she was nauseous, the doctor prescribed suppositories. Later in the week, when Esther continued to complain of nausea, further suppositories were given. 4. On Monday, October 28, I again asked if it would be possible to speak with a doctor. I was again informed by Heartland staff that the doctor was out making calls and could not be reached. I again tried Dr. Cohn's office and was informed by a nurse named Scott that the matter was entirely in Heartland's hands. When I explained that I could not reach a medical decision maker and it was important, Scott called back to tell me that I needed to speak with Heartland's "charge nurse," named "Chris," and that I should not be calling Dr. Cohn's office any more. I went to the 2nd floor East front desk to ask for "Chris," and was told by the nurses that they would convey a message instead. I verbally requested a meeting with Chris, myself, and Mr. and Mrs. Aronin to review her condition, past history and medications that were not on their records, and convey our concerns about the nausea and lack of appetite. We did not get a reply. Monday afternoon, November 4, I again asked to see "Chris" or Dr. Sood, and was told by the nurse at the front desk East that she would "deliver a message." I left a written note at the nurses station requesting an exam and 6-12 injection for Mrs. Aronin, and mentioned my concerns to Pat, a nurse, and Vea Reese, a social worker. 5. THE CLIMAX: On Tuesday, November 5, Mrs. Aronin started vomiting violently after eating 1/4 of a sandwich a family member brought her. The vomiting continued for over an hour, Mrs. Aronin's entire body was shaking and a very thick yellow substance was coming up. I feared she would fall and damage her new hip. I tried to reach a nurse with the call button - after 45 minutes no one showed up, so I cleaned up Mrs. Aronin and tried to again reach Dr. Cohn's office to ask if they could assist in my reaching someone in charge at Heartland. I was told they "could do nothing, not even give me a phone number.
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The next morning, November 4, Mrs. Aronin was weighed. She had lost approximately 18 Ibs. in under two weeks ( Mrs. Aronin is 83 yrs. old). Suppositories for nausea were continued no one on staff addressed her nausea and appetite problem. Thursday evening, November 7 at 4:50 p.m., I telephoned Mrs. Aronin before leaving for a meeting. She wasn't feeling well and was waiting to be helped into bed. At exactly 6:20 p.m. I received an emergency "Beeper Signal" from Esther while I was at a meeting and I called back on my cellular phone. She was still sitting in the chair, nauseated, and waiting for toilet and bed assistance. She had been vomiting and was crying. I arrived at Heartland at 6:45 p.m. and found Mrs. Aronin slumped over in the same chair, wet from her urine, tears running down her cheeks. Most of the beds in her infirmary wing had been changed, even those in rooms on either side of hers. I helped lift her, cleaned her (she clearly hadn't been bathed in some time), took her to the bathroom, and then searched for sheets to change the bed - which I did myself.

I asked the nurse at the front desk if anyone had checked or taken any medical tests on Mrs. Aronin. I was told that Dr. Sood had seen her on Tuesday. No response to my note or on whether the B-12 shot had been given. Note: When I went to the front desk to request bedding from Marcia, the nurse, there were two women standing there-- the women who made up the beds. I clearly saw them throw "grins and stares" at each other. Obviously they were aware Mrs. Aronin had been calling them since 4:45 p.m.! I then left a written note to Vea Reese, Heartland's social worker, to finalize arrangements for Mrs. Aronin, that we had decided to remove her from the facility on Friday, November 8 for Mrs. Aronin's own health and safety. 6. GRAND FINALE: Friday morning, November 8 - For the first time since arriving, Mrs. Aronin is bathed and give a blood test. Mr. and Mrs. Aronin remained firm about their decision to leave Heartland even though no physician would see her first. At about 4 p.m. I received a phone call from my mother saying she was going home. Just at that moment someone walked into her room with the medical lab results. I asked Mrs. Aronin what the conclusion was - no one there would inform us. Then Mrs. Aronin put Vea Reese, the social worker, on the phone. Vea said the results showed "something was not right." I then asked Vea if we could have someone interpret the tests before Mrs. Aronin departed, in case of serious problems. None of the staff would explain the test results to the Aronins or on the phone to me. They also would not give a copy of the lab work to us! After some pleading on my part, Vea agreed to fax the lab work to me. I called Dr. Cohn's office for any sort of guidance, but was told it was not their responsibility and they could not assist with so much as a medical visit to any qualifited physician.
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7. FINAL HOSPITALIZATION: On Saturday, November 9, Mrs. Aronin was very nauseated, shaky and running a temperature. I tried all the Cleveland Clinic's emergency telephone numbers. The only response I could get was "call 911." I literally begged for the "doctor on call" to help as Mrs. Aronin was in no condition to attempt to climb into a car and we wanted a medical facility that was familiar with her history. Although a "Dr. Bendeck" was on call for "Dr. Kenny," the supervisor refused to allow me access to him by phone or in person with Mrs. Aronin's lab results in hand. Mr. Aronin called the Wynmoor Village paramedics, who said Mrs. Aronin was "stable" and not an emergency. Yet she continued to convulse. I WAS ABLE TO REACH A DOCTOR FRIEND OVER THE PHONE, WHO WAS KIND ENOUGH TO INTERPRET SOME OF THE LAB NUMBERS OVER THE PHONE. HE SAID, "THOSE HIGH NUMBERS ARE ASSOCIATED WITH THE PANCREAS. THE PANCREAS IS EITHER IRRITATED OR SOMETHING IS BLOCKED. ESTHER SHOULD STOP EATING AND GET TO A HOSPITAL WHERE SHE SHOULD BE FED INTRAVENOUSLY." A SECOND DOCTOR ACQUAINTANCE AGREED. BOTH PHYSICIANS SAID THE PARAMEDICS WERE INCORRECT AND, CONSIDERING HER AGE, IT WAS AN EMERGENCY. We took Mrs. Aronin to the Columbia Northwest Regional Emergency room in Margate. Mrs. Aronin waited four hours to be seen. It was another four hours before Mrs. Aronin was given a room - we were told that Dr. Sood was the doctor in charge and that the hospital was trying to reach her for permission for a room. Mrs. Aronin remained on intravenous at the hospital for almost three days. At this time, Dr. Sood and hospital staff were very attentive.

CONCLUSION ABOUT HEARTLAND

If the doctor at Heartland had ordered the bloodwork sooner, then perhaps Mrs. Aronin would not have needed to endure weeks of unnecessary pain and suffering, and the pancreas problem would have been found sooner. It was added stress on a patient who was already going through a major ordeal to recover from hip operation. The doctor involved with Heartland was Dr. Sood. This doctor caused a lot of pain and unnecessary stress to Esther Aronin and her family through her inaccessibility, and a demonstrated lack of response to medical complaints or family requests. We recommend that, in the future, patients should NOT be sent to Heartland until staff improves its response time (especially when the patient has to go to the bathroom) and until their physician and medical staff have taken some remedial training on basic care of patients and family public relations. We also noted the following in reference to Heartland of Tamarac: 1) Problem with Bathroom Assistance: Esther was often unable to receive a response when she needed to go to the bathroom and it was not unusual for her to wait up to 60 minutes or longer. In desperation, she would use the bedpan herself and frequently it spilled, leaving her with a wet bed.
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2) Problem with Daily Living Assistance: It is hard to believe that Mrs. Aronin's daughter, 15 miles away, could respond to a plea to be helped to bed more quickly than the staff or that a patient should go nearly two weeks without being fully bathed. Perhaps the staff can not sufficiently respond due to workload. Whatever the reason, it is difficult to justify adding to the stress level of a patient who is recently emerged from serious surgery. 3) Marginal Physical Therapy: Therapy was marginal at best. One day, helping Esther brush her teeth was counted as a full day's therapy requirement, as was helping her to get dressed. She was told that 1/2 hour a day of therapy is all that is required by the HMO. The rest of the time Esther was left mostly in her bed. Under such circumstances, a patient is less likely to recover quickly. 4) * *Subtle Recriminations Against Patients/Fear of Reprisal as mentioned earlier: There was a noticeable change in attitude and manner of the staff when Mrs. Aronin or her family had to make repeated requests for assistance or response. We are not demeaning the professional abilities of the staff, but it was clear to her family members that Mrs. Aronin received silence, longer response times and more curt and less cordial "handling" by staff after we voiced any complaints. Mrs. Aronin become afraid to speak up about her increasing discomfort because she believed that a negative staff reaction would follow which would again affect response time level of attention. CONFUSION REGARDING CLEVELAND CLINIC'S ROLE We have been informed that when a Cleveland Clinic patient goes under PCA care, the Cleveland Clinic staff is not supposed to be involved any longer. Exactly when and how is this fine line drawn? Clearly, Mrs. Aronin's family felt she and they were literally dumped and left to solve problems and red tape on their own. Perhaps this would have been easier with a written diagram explaining who was in charge, what numbers to call, and what to do if the person in charge of you cannot be reached - especially one thinks it may be a health emergency. When a surgery patient at Cleveland Clinic moves on to rehab under PCA, is there any responsibility on the part of the Cleveland Clinic for that patient? (Esther's surgery was a success, but without nearly desperate intervention by her family, and the kindness of a "spectator" physician, it is conceivable she may not have survived thanks to undiagnosed complications.) Perhaps upset patients and families should be given the benefit of a doubt, that the patient's condition really is serious and that the family is not unreasonable and hysterical. What is the purpose of the Cleveland Clinic's "Doctor on Call" telephone number? The Aronins are current in their HMO payments, yet were clearly refused any assistance.

Aronin

Responsiveness and Accessibility: Telling a convulsing patient's daughter that "it's not your job" is at best not very good public relations. During Mrs. Aronin's convulsive vomiting on November 5, when I could not get Heartland to respond, I spoke with staff in Dr. Cohn's office. They remained polite and businesslike, but clearly conveyed the message that they would not respond to our requests for assistance or direction. Perhaps they might have supplied an alternative emergency procedure? A PCA telephone number? Reassurance?

My mother, Esther Aronin, has always held the staff at Cleveland Clinic in high regard and continues to do so. Since the above incidents she has received very responsive medical treatment. I can only relate what my experience was during a serious health situation. This letter was purposely delayed so as to allow time for tempers to cool and the health crisis to pass. My mother, Mrs. Aronin, has still had unexplained bouts of shaking and nausea and is still too weak to walk more than about 20 or 30 feet. Her hip surgery took place exactly two months ago. This correspondence is long, but I hope that it might give cause for reflection on the part of the health care officials and staff involved, and perhaps influence a change in attitude, behavior or procedure. This incident has certainly influenced our friends and family in their future selection of medical facilities and insurance programs. Sincerely,

Janus McCrea 954 463 0158,

fax 954 462 4423

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Jk File: Mom Affairs - Conversations to Remember This is to confirm our conversation last night, Tuesday. (Late Sept. '01) Mother called me at 7:15 p.m. She said she couldn't believe that Archie had been paying Ann $350 per week. She insisted I speak with Archie. Archies got on the line and asked what's going on? I explained that I had told the Aronins this on about 6 different occasions since Mother returned home. 1. We needed 24 hour help. 2. Insurance only covered 40 hrs. per week 3. All qualified help charged a minimum of $8 per hour, and would only work a minimum of 6 - 8 hrs per night. 4. If they arrived about 9 p.m. and left at 7 a.m. that would be 10 hours at

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5. This meant that they would leave in the middle of the night or before morning if we cut their hours. Mother was falling and hurting herself (and terrifying Archie) and would not wait to get up in the morning. We had to have someone there. 6. Ann agreed to spend nights there for $50 a night. 7. We did not "count" the exact hours ... it was most important that she be there at the times Esther most often needed help. 8. Janus and Stephan called ads, agencies and spoke with private aides. They have a list of everyone they spoke with. We could not find night help to cover the stretch of time.you needed (10 p.m. and 7 a.m most important) for less that $56 if they arrived exactly at 10 pm and left exactly at 7 am!) Most wouldn't work those hours

FYI: The Becks did not have 24 hour free or insured help. They had a policy that covered 40 hours per week also. The Beck girls paid for the other 16 hours of help per day at $8 per hour. About the Cost: You turned down the, Independent Living partly because of the cost. The cost was about $4000 per month with meals for two people. I you wanted someone in your house to help you still needed someone to hire on your own. If you hired someone on your own 10 hours per day 'at $8 per hour every day for 30 days it came to $2240. That's 10 hours per day (or night). You would use your insurance for the other 8 hours - total: 18 hours per day of help.