LITTLE ROCK — It was 7:35 p.m. on April 17, 2001, and something strange was about to happen on living unit 6 Cedar.
Someone shut off the feeding pump for Marie (not her real name), disconnected the tubing and covered her face with a white towel.
Her recliner was positioned near the kitchen door. The kitchen phone was off the hook.
Four life-skills trainers were working with residents in other areas of that unit. That left 16 residents alone.
And then Marie screamed.
A worker rushed in and saw the towel over Marie's face. The towel's edge was tucked under her chin, which was red from ear to ear. Her right arm was red from wrist to elbow.
"She was just hysterical," said staff member Melissa Boyce.
The towel looked "like someone laid it over her face and tucked or tightened it under her chin," Boyce said. "There was a red mark... it's under the chin from jaw line to jaw line. ... It looked like somebody had put the towel on her, you know, tightened it down on her chin.
"It was pretty tight to her face because she was, when she opened her mouth she was sucking the towel in."
The presence of the towel was strange in itself. The staff never used a towel on the woman because she wore a colored bib.
"She was visibly upset, and she was crying," another staff member said.
Marie, who answers "yes" and "no" to questions by raising her arms, said it was a man who put the towel over her face. She did not know the man.
A staff member had previously placed 390 cc in the woman's feeding bag. There were 200 cc left when the tube was disconnected and the pump turned off.
All staff members denied turning off the pump. Residents in the unit are immobile or are able to walk only with assistance, so they were ruled out.
The Conway center investigated but came to no conclusions. Some staff members were given written warnings for leaving residents unattended for up to 10 minutes.
Why weren't the police called?
"I don't think she [Marie] had any emotional harm," said Superintendent Clark.
"We called the sister who said that she quite often yells and screams and does stuff. So I don't see any reason to call the police. If I thought an intruder had been here, I'd have called the police."
The center was cited by state investigators in May 2001 for failing to monitor the woman in this incident.
The woman "received physical and psychological harm," the state concluded.
The Conway center's internal investigators could not determine what happened, although records indicate the staff suspected someone had come into the facility undetected. The outside door to the unit had not been locked and an order was given to lock all doors after dark.
But a year later, Marie's incident would come up again.
Clark wrote a letter to a state police investigator in Oct. 9, 2001, about the events involving Marie.
"I believe her feeding pump being turned off was mostly likely performed by nursing staff in that the plug was inserted back into the feeding tube itself after it was disconnected," he wrote. "This would seem to indicate to me that nursing staff were involved."
Concerning the towel over the woman's face, "I also have suspicions that this may have been performed by staff [name deleted] as a 'spiteful' type reaction to another staff [name deleted]," he wrote.
Clark was interviewed by Long-Term Care investigators about the memo, and he stated it was part of the "rumor mill" and "nothing concrete."
The state Office of Long Term Care cited the Conway facility on May 22, 2002, for not reporting that suspicion to the state and not investigating it.
That was not the only incident of its kind.
The night after Marie's feeding tube was disconnected and feeding pump turned off, a similar incident occurred with a 9-year-old boy in unit 1 Willow, the unit for medically fragile men.
Between 3:30 a.m. and 4 a.m. the boy's feeding pump was shut off and cleared. The four staff members present denied turning off the tube or resetting it.
The feeding had started at 2 a.m. with 200 cc. At the time the pump was shut down, it appeared to have 120 cc left.
The boy is profoundly mentally retarded and suffers from cortical blindness, cerebral palsy and seizure disorders. He was not feeling well and was moved to the day room so he could be watched closely.
None of the outside doors were locked. The staff had not seen the directive to lock the doors.
His family was not notified of the incident because he was not injured. The short length of time his feeding was delayed did not hurt him, the Conway center concluded.
Staff members who had left that unit were given written warnings.
The Conway center was cited by Long Term Care in May 2001 for leaving the boy unattended for an extended period of time.
Copyright © 2002, Arkansas Democrat-Gazette, Inc. All rights reserved.