Lawsuit alleges neglect caused Rainier School resident’s death after bunion surgery
The family of a woman who lived at a state facility for adults with developmental disabilities has sued the state, alleging that neglect caused her death in 2017 following bunion surgery.
The lawsuit says 33-year-old JoHanna Pratt died from a pulmonary embolism after the surgery, and that Rainier School staff had instructions from her doctor to monitor Pratt for any trouble breathing.
The state Department of Social and Health Services operates the facility in Buckley.
“She was completely dependent on the staff of Rainier School, and they let her down in the worst possible way, causing her death,” one attorney for Pratt’s estate, Chris Carney, said in a statement. “This tragedy could have been avoided if the State had simply followed the instructions given by JoHanna’s doctor. The State must be held accountable.”
A DSHS spokesperson, Lisa Copeland, said in a statement Friday: “Unfortunately we cannot speak to pending litigation. But I can tell you we take all allegations very seriously. The safety and well-being of our clients is our first priority. We are dedicated to our mission of transforming lives by providing support and fostering relationships that empower (them) to live the life they choose to live.”
The lawsuit, filed Thursday in Pierce County Superior Court, seeks unspecified damages.
It gives this account of what happened:
Pratt had a “mild intellectual disability,” and started living at the Rainier School in 2012.
“Prior to her death, Ms. Pratt had been assessed for a housing placement in the community outside of Rainier School,” the complaint said. “The assessment indicated that she could be placed successfully in the community, and planning for her discharge from Rainier School was underway at the time of her death. Had Ms. Pratt survived, she would have been discharged to a housing placement in the community and could have maintained employment in the community for decades.”
The bunion removal surgery on her right foot was done at a hospital Nov. 3, 2017, and she was back at the Rainier School later that day with a wheelchair and cast.
“Prior to and again following Plaintiff’s surgery, Plaintiff’s podiatrist provided written instructions to Rainier School staff emphasizing that they should seek immediate medical attention for Plaintiff if she developed any symptoms of shortness of breath,” the lawsuit said. “These warnings were consistent with medical standards of care relating to the well-known risk of Deep Vein Thrombosis, a medical condition occurring when a blood clot forms in the blood vessels of the leg. This condition is life-threatening if the clot travels through blood vessels into the lungs, where it can cause a fatal pulmonary embolism.”
Four days later a Rainier nurse noted Pratt “had difficulty breathing and that she was experiencing some anxiety,” after Pratt said she was having trouble breathing and that she did not feel well.
Her pulse was 116 beats per minute.
The next day Pratt said she had chest pain and said again that she was having trouble breathing, Rainier nursing staff evaluated her, and 911 was called.
On the way to the ambulance, on a stretcher, Pratt took off an oxygen mask EMTs had given her and said repeatedly that she couldn’t breathe.
She was “transported out the door yelling and screaming,” the lawsuit said.
Pratt went into cardiac arrest and died in the ambulance outside the cottage where she lived, after 33 minutes of CPR by the EMTs.
“If Rainier staff had sought immediate medical assistance for Ms. Pratt when her shortness of breath first occurred, her life would have been saved,” the lawsuit said.
An investigation by the DSHS Developmental Disability Administration found the first nurse should have told a Rainier doctor about Pratt’s pulse, and that the next day staff should have called 911 about Pratt’s chest pain right away, not the facility nurse.
The lawsuit says: “An investigation by the State of Washington Aging and Long-Term Support Administration found that Rainier’s failure to develop or update medical care plans for clients returning to the facility following medical care in the community violated a federal rule requiring that state DDA facilities have medical care plans for all residents determined to require 24-hour nursing care,” and that “The ALTSA survey report resulted in the issuance of an ‘immediate jeopardy level citation’ for Rainier’s failure to protect facility residents.”
A press release from Carney’s law firm and the nonprofit Disability Rights Washington noted that last year the Centers for Medicare and Medicaid Services “terminated federal funding for part of Rainier School, citing the institution’s failure to meet basic safety and health requirements.”
The release also said that Pratt and two others at the Rainier School sued a year before she died “to vindicate their right under federal law to live independent lives in the community,” and that “the state settled with the remaining plaintiffs in C.F. v. Strange, et al, agreeing to concerted efforts to ensure their release from Rainier School to community living, as Ms. Pratt wanted to do.”
David Carlson, the Director of Advocacy at Disability Rights Washington, said in a statement: “As long as the State continues to isolate people who need support in large, decaying institutions like Rainier School, tragedies like this one will continue to occur. We need to move forward to creating supportive and inclusive community placements for people with disabilities that will foster their independence and well-being instead of institutions.”
Pratt’s mother, Marvieen Pratt, said in the press release: “I spoke to JoHanna nearly every day, I loved her so much and our relationship brought me so much joy. We are devastated to have lost her like this, and I really hope that this can be a wake up call for the State to keep people safe at Rainier School.”
This story was originally published October 26, 2020 at 5:45 AM.
