He was sick, he told a Veterans Administration employee over the phone. Five strokes had left him paralyzed on one side of his body. Diabetes had taken his eyesight and his right leg below his knee.
He wanted out because the people who agreed to be his caregivers in exchange for $1,200 a month weren’t taking care of him, he complained on the VA call line.
VA medical records, Department of Community Health inspection reports and files from local law enforcement show that over the following months, Lauderdale repeatedly asked for help to get out of Open Arms, but he was always returned. In 14 months he would be dead because a bedsore became so infected the infection seeped into his bones, eating the flesh and muscle, leaving his tailbone exposed. It was clearly, his last physician said, medical neglect.
No one has been held responsible for his death, or for the depletion of his bank account.
Lauderdale’s only sibling, Janey Sims, said she felt hopeless that any justice would be done. But what’s most important, she said, is to ensure no other veteran will go through what he did.
Lauderdale served in the Army and the Marines. He lived in the VA psychiatric ward in Augusta for about two years and he desperately wanted out. When Sarah Ellison said she had a bed available at Open Arms he was ecstatic. He ignored warnings that the home was not on the agency’s approved list of personal care homes. He signed a release and on Oct . 1, 2011, moved into Open Arms. Three days later he called the VA help line. He had changed his mind.
INTERVIEW: Sarah Ellison speaks to investigator
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Lauderdale was fine, just being demanding, the unnamed Open Arms employee who took the phone from Lauderdale told his social worker on Oct. 4, 2011.
It was the start of a pattern.
On Oct. 19, 2011, at a follow-up appointment with his eye doctor who had operated on him, Lauderdale tearfully told a social worker he wanted to go back to the VA. He had marks on his arm from scratching bedbug bites. He begged the social worker, Jan McWilliams, not to tell Ellison he wanted to leave her personal care home. McWilliams agreed and started the process to have Lauderdale moved back to the uptown VA, according to his medical records.
But Lauderdale’s regular social worker, Latorja O’Bryant called Ellison and told her what was going on. O’Bryant told Lauderdale he had to return to Open Arms or find someplace else to live, according to the medical records.
Lauderdale went back to Open Arms.
A month later he told the eye doctor he wasn’t being given his medicine as directed. On Jan. 4, 2012, at a physical therapy consult, the therapist noted Lauderdale had a bedsore on his buttocks she estimated was smaller than a dime. Lauderdale told her he wasn’t able to turn himself over and asked about getting a hospital bed with an overhead grab bar to help him. Lauderdale said no one would help him turn over at Open Arms, the therapist noted in Lauderdale’s medical record.
But Ellison and the Open Arms employee who took charge of Lauderdale’s care, Sandra Graham, both told The Chronicle that they took good care of Lauderdale, ensuring he was fed and bathed and given his medicines. “He was happy living here,” Ellison said.
INTERVIEW: Sandra Graham speaks to investigator
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Lauderdale, however, kept complaining over the subsequent months that he was being neglected. He failed to show for eight doctor appointments, according to his VA medical records. In the final months, Lauderdale called 911 for help at least eight times. Medical records show his glucose sky-rocketing to five times the normal level. After each trip to emergency rooms at the VA, Augusta University Medical Center, Trinity and University, Lauderdale was sent back to Open Arms.
He was sent back even after Gold Cross Paramedic Mark Smith told emergency room staff he found Lauderdale locked in a dark bedroom lying in his own waste in a room reeking of urine.
His bedsores progressed from stage II to stage IV.
Lisa Aycock of Adult Protective Services would later say she only had one complaint about Lauderdale and that was from Lauderdale himself. But the paramedic said he twice called Adult Protect Services. Lauderdale’s sister said she called. So did at least one hospital social worker. District Attorney Natalie Paine, then an assistant DA, also called, she wrote to the sheriff’s office in requesting an investigation.
Sims called the day after receiving a frantic call for help from her brother in the fall of 2012. Ill herself and recovering from surgery, she asked her husband, Mike, to go to her brother. Mike found Lauderdale naked on the floor of his bedroom. It was so nasty your feet stuck to the floor, Mike Sims said.
Janey Sims said she thought she was supposed to call Adult Protective Services to get help for her brother.
A year earlier, she had told her brother’s VA social worker that Lauderdale could not move into Open Arms because the bathroom was not handicapped accessible. But a week later, Ellison offered Lauderdale a room. How, she asked, could the VA let him leave when he was mentally ill and she had his medical power of attorney?
In the fall of 2012, Sims also called the state’s Department of Community Health to complain about Open Arms.
A Nov. 1, 2012, inspection by the department in response to the complaint found 39 violations, including expired fire extinguisher; a rotted bathroom floor that Open Arms staff said was caused by rats; roaches and assorted other bugs crawling on the floors, walls and ceiling; and the overwhelming stench of urine in Lauderdale’s room.
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Seven people were living in the home that was only licensed to have six residents. Lauderdale and a second resident were confined to wheelchairs in a house without a handicapped accessible bathroom, according to the inspection report.
Mark Smith responded to the last 911 call from Lauderdale and the paramedic this time asked dispatch to send a sheriff’s deputy to see the conditions of the home. This time, Lauderdale was belted into a wheelchair completely unresponsive. It was Dec. 27, 2012. It was Lauderdale’s last trip to an emergency room.
The infection from the bedsore on his backside had spread to Lauderdale’s bones. On Oct. 28, 2012, the bedsore was the size of a quarter. In January 2013, it was 15 by 15 centimeters, about the size of a small frying pan, and oozing, Dr. Parth Jamindar reported. Lauderdale definitely did not get the care he needed. It was obvious medical neglect, Jamindar told Richmond County Sheriff’s Sgt. Chris Langford.
INTERVIEW: Dr. Parth Jamindar speaks to investigator
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Ellison insisted to a reporter that Lauderdale didn’t have any sores when he left Open Arms. Graham said he only had one small red spot. Ellison blamed the hospital staff for not taking care of Lauderdale. Informed the medical records recorded Lauderdale’s sores, Ellison said the VA records must have been doctored. Both women said they cared for Lauderdale as if he was family.
The first time Smith responded to a 911 call at Open Arms, on Nov. 13, 2012, he wrote that he found Lauderdale locked in the back room. There was no reason to lock him in, he couldn’t go anywhere, he couldn’t even reach the light switch, Smith told Langford. That’s why he called Adult Protective Services. He handed Langford the pictures he took to document the scene.
Lauderdale told Smith and his partner that he didn’t feel safe at Open Arms and didn’t want to go back. But he was too scared to say anything in front of the staff, Smith said. But at Trinity Hospital, he told the social worker he wanted to go back to Open Arms, according to medical records.
Graham said she bathed Lauderdale every day. If he was sitting in his own waste he was doing it out of spite to get back at the staff when he didn’t get his way and get the attention he demanded, Graham said. “They just don’t know what we went through,” she told a sheriff’s investigator and The Chronicle.
He could be the sweetest person around but he could also be evil, she said.
Ellison provided meals, but Lauderdale insisted on ordering food from restaurants, Graham said. That’s why his diabetes was so out of control, but he wouldn’t listen to her warnings, Graham said.
When sheriff investigators asked Ellison and Graham about Lauderdale’s bank account, both insisted no one accessed the account except when Ellison took out the monthly payment for Open Arms or when Lauderdale wanted cash. Sims found that impossible to believe, considering her brother received $1,700 monthly and had more than $20,000 in October 2011 and nearly nothing by the time he died.
His bank card was used a lot.
It was used at Summerville Ace liquor store on Dec. 13, 2011, for $543.53, his bank records show. Lauderdale didn’t drink alcohol, his sister said. He never tested positive for alcohol at medical visits at which he was normally tested for alcohol, according to his medical records.
On March 5, 2012, there were purchases of more than $1,400 at Best Buy, the same day Lauderdale called for an appointment with a VA doctor because, he said, he had a rash over his amputated leg that oozed puss if he scratched it.
Lauderdale saw his regular doctor on April 24, 2012, when his glucose level was in the 200 range. Normal is 70 to 100. He also saw his eye doctor that day, his first visit since he begged for help to get out of Open Arms six months earlier. He told them he couldn’t get to appointments because Open Arms staff wouldn’t drive him to the VA.
Ellison and Graham said Lauderdale canceled his own appointments. They couldn’t make him do anything he didn’t want to do, they said.
Lauderdale failed to show for doctor’s appointments in May, June and twice in July of 2012. When he finally saw his doctor on Sept. 23 of that year, his glucose level was 308. He canceled his next appointment three days later because he had no ride, according to medical records.
Lauderdale called 911 for help on Oct. 18, 2012. He told Smith he didn’t want to go back. That day, $200 was withdrawn from his back account. A week later when taken to the VA emergency room, his glucose level was 400. He asked a nurse to help him turn on his side because of a sore on his tailbone. The sore was the size of a quarter. She moved his leg to examine his back side and Lauderdale yelled in pain. His underside was raw and red, she noted in the medical record.
On Nov. 6, 2012, five days after his doctor noted Lauderdale had an open lesion with yellow pus and bloody drainage, $800 was withdrawn from his bank account.
On Nov. 13, 2012, Smith had to wake up a staff person to unlock Lauderdale’s bedroom door. Lauderdale was yelling for help, in pain with a urinary tract infection, Smith said.
Five days later EMS was back for Lauderdale. They could smell urine from the outside of the house. They found Lauderdale in urine-soaked clothing.
On Nov. 23, 2012, back at the VA’s emergency room, a doctor noted that EMS found Lauderdale lying in his own waste, with dirty bedpans on the floor. “Don’t care for him. Maybe right,” a doctor wrote.
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He was cared for, Graham said, but Lauderdale kept his room locked and wouldn’t let them in to clean. He knocked over bottles of urine all the time, Ellison said. She thought he did it by accident but other staff members thought it was intentional.
On Dec. 8, 2012, at the emergency room at AU Medical Center, Lauderdale’s glucose level was 566 — more than five times the normal range. He was a no-show for his Dec. 12 follow-up doctor’s appointment.
On Christmas Eve, $200 in cash was withdrawn from his account. Three days later, Smith transported Lauderdale from Open Arms for the last time. As Lauderdale lay in a hospital bed slowly dying, his bank account was used to pay utilities bills and make a car payment for an Open Arms employee.
On Jan. 7, 2013, Ellison withdrew $1,250 from Lauderdale’s account because, she told the sheriff investigator, he wanted to pay for the month in advance.
Lauderdale died Jan. 31, 2013.
Langford closed the file on Lauderdale as “cleared other” after then-District Attorney Ashley Wright wrote there wasn’t sufficient evidence to prove a crime caused Lauderdale’s death. There is no indication anyone interviewed any of the other residents of Open Arms. Neither law enforcement nor medical staff noted any review of Lauderdale’s medication and pharmacy records to determine if he was getting his multiple medications as prescribed, according to documents. Although Smith suggested other ambulance staff had interactions with Lauderdale and might have more information, no one else was interviewed.
The theft investigation of Lauderdale’s depleted bank account faded away with no arrests.
The Department of Community Health took no adverse action against Ellison, according to records provided in response to an Open Records request. The next regular inspection of Open Arms wasn’t until June 2013. The Department of Community Health inspector found loose pills in roach droppings in a medicine cabinet, just as another inspector found in November 2012. The urine smell in the front bedroom was so bad the inspector couldn’t stay in the room.
Graham, Lauderdale’s main caregiver, became the administrator of Marie’s Personal Care Home. In May 2014, Ellison incorporated Simple Blessings as a charity providing assisted-living care. Both homes have been cited for Department of Community Health violations, including a staff member convicted of a violent felony at Simple Blessings last May.
Asked to respond to what happened to Open Arms following Lauderdale’s death, the Community Health Division spokeswoman Lisa Marie Shekell said there would be no comment. The Adult Protective Services didn’t return a call seeking comment. The same is true for the VA.
Open Arms remained open through April 2015 when Ellison, now associated with two other Augusta personal care homes, closed it.
Reach Sandy Hodson at (706) 823-3226 or firstname.lastname@example.org.
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