Nursing home homicide exposes previous problems

(File Photo)

By Erich Wagner (File photo)

A Del Ray nursing home that was the site of a January homicide has a history of service and policy deficiencies, including one that may have contributed to the circumstances surrounding the death of an 82-year-old patient.

On January 8, two residents of the Envoy of Alexandria, located at 900 Virginia Ave., got into a fight, according to police accounts. Edward Heitz was hospitalized briefly and released back to the nursing home.

But he died just a few days later — January 11.

The incident was not considered a homicide until May, when the medical examiner’s office determined blunt-force trauma was the cause of death. The suspect in the homicide is a 62-year-old resident of the facility, but police are undecided on pressing charges, citing both men’s pre-existing medical conditions.

According to publicly available federal inspection records of nursing homes on the receiving end of Medicare funding, several deficiencies have been documented at Envoy in recent years. They range from not developing policies preventing the mistreatment of residents to quality of care and include minor administrative issues.

Envoy reported that it had corrected the problems listed in a December report January 7 — a day prior to the fighting incident.

But a February complaint investigation report obtained from the Centers for Medicare and Medicaid Services by the Alexandria Times — through a Freedom of Information Act request — indicated that the fight brought to light additional problems at Envoy.

The report, which health officials believe Heitz’s death triggered, found that the nursing home lacked necessary policies to deal with combative or easily agitated residents.

“[The] facility staff failed to develop a comprehensive care plan to address behaviors for two of five residents in the survey sample,” the inspector wrote.

The report focuses on two residents: a patient known as resident No. 2 and a former patient referred to as resident No. 5.

Although No. 2 had been through several room changes since his admission in 2009 — as well as two documented altercations with roommates — the inspector said that his care plan did not adequately address his behavior.

“The comprehensive care plan dated [August 6, 2012,] documented … ‘Assess resident for effectiveness of prescribed medication in addressing resident’s mood/behavior issues,’” the report said. “No further information regarding the resident’s behaviors was documented on the care plan.”

On January 8, resident No. 2’s patient record included a physician order for a room change, without explanation.

Resident No. 5 only had moved into the facility December 20, 2012, but the inspector wrote that there were several documented incidents of agitation — from curses and insults leveled at staff to throwing chairs during his previous stay at an assisted living facility — in weekly progress reports. Those incidents were not adequately reflected in his care plan.

The report stated that No. 5 had a “re-admission” January 9, one day after the altercation leading to Heitz’s death. And in Envoy’s response, which outlined plans to correct the issues brought up in the report, the facility said, “Resident No. 5 was discharged” January 11 — the day of Heitz’s death.

In an interview with an Envoy social worker, an inspector brought up No. 5’s agitation incidents.

“When asked if she was aware of any behaviors exhibited by resident No. 5, [the social worker] stated, ‘Not that I saw; I heard reports that he got upset and would pull his fist but never hit anyone,’” the report said. “[When] asked if resident No. 5’s behaviors should be care planned, [the social worker] stated, ‘Yes, they should have been.’”

The inspector noted that the director of nursing and administrator at the facility “stated that they were unaware of the documented behaviors of resident No. 5.”

MaryAnn Griffin, director of the city adult services office, said that while she could not speak specifically about Envoy or the homicide, all long-stay nursing home patients are required to have comprehensive plans of care established within two weeks of admission.

And those plans must be updated on a quarterly basis. Griffin said the documents should address behavioral issues as well as any mental or physical impairment.

Lakesha Davis, executive director at Envoy of Alexandria, did not return calls for comment. But in the facility’s response to the report, the nursing home said it had corrected all issues by March 7.

“An [sic] review of current residents in the facility was conducted on or before [March 7] to ensure that behaviors are addressed on their plan of care,” wrote Envoy officials. “The staff development coordinator will re-educate staff on addressing resident behaviors on the plan of care …

“The unit manager/designee will review 10 percent of the residents with behaviors on a weekly basis for [three] months to ensure that behaviors are addressed on the residents’ plan of care.”



  1. I would agree that APD should think about pressing charges, or at the very least present the facts to a grand jury. Putting myself in the place of the victim’s family, unless the suspect is on his deathbed, I would want the case to at least make it to court.

  2. I have a sister who is a resident at The Envoy. I was not informed of the incident that occured where the patient lost his life. I feel I should have been inforned. Before I placed my sister there I was told they had provisions for residents with dementia and alzhimers. Not true. I wittnessed two incidents myself one between an attendant and a resident and another incident between the same resident and another resident which I interceeded in. I realize that a lot of the residents probably receive medicare and medicade but a more detailed care plan should be in place for those who have memory impairment. I do appreciate the fact that the place is kept clean and I think the food is fairly good. I have had to suggest that the fingernails of residents should be more carefully examined for cleanlyness, to keep deseases down.

  3. I briefly placed my mother at this facility, and I immediately regretted having done so. The admissions staff blatantly lied to me so that my self-paying mother, at $305 per day, would reside at Envoy (cha-ching!). In return for that fee, she got nothing more than 3 tray meals and a bed in a crowded, dismal room (her bed was literally inches away from that of her roommate; and, although Mom was a fall risk and needed a walker, it was kept a distance away, against a wall, because there wasn’t enough space to put it near her bed).

    This facility is a disgrace. I have no idea how it’s stayed under the inspection radar for so long and kept its license. With any luck, this new story will call attention to the dismal conditions and shut-down the place.

  4. Has anyone investigated an employee named Sarah, who was responsible for room assignments? (I don’t know if she’s still on staff.)

    While my mother was spending a miserable month in this place — I removed her as soon as possible — she stayed in three rooms. One of her roommates had also been there for a month; she’d been moved repeatedly and told me that my mother was the 3rd person she’d been forced to live with.

    I understand that SNF demographics are fluid and constantly changing. Does this mean that SNF residents should be frequently relocated and placed with strangers? For anyone suffering with dementia, changes are traumatic and often harmful. My mother’s current SNF, where she’s happy and treated well, makes every effort to avoid moving people. Her current SNF also has private rooms for nearly every resident, a safer and much more stable environment.