Best Place to Die

by Charles Atkins

  ‘It wasn’t a nursing home,’ Lil said. She scanned down to the signature lines and next to the space for attending MD/DO the name: Norman Trask, MD. A supposedly retired surgeon signing forms for patients who weren’t in a nursing home – what was in it for him?

  ‘Sure felt like a nursing home,’ Rose said, looking at Ada.

  Lil’s head swam as the line of investigation she needed to pursue took shape. Get a list of the residents, find out how many were on Medicaid, try to contact either them or their families, download policies and definitions for nursing homes, get the rules for Medicaid eligibility . . . And something else . . . ‘Ada?’ She walked away from Rose to the far side of the little stone wall that provided the border for the seating area. Ada followed. ‘I don’t think Kyle’s been entirely honest with us.’

  ‘About?’

  ‘Think about it. His grandmother is too demented to be in her own apartment. She’s getting billed nursing-home-level care for services she’s not receiving. He must have known about that. What if?’

  ‘What if he’s part of it?’ she stated. ‘It seems he would have to have known something. But he seems so nice. In my heart I can’t believe he’s faking that. Look at how hard he’s trying to help people, and how devoted he is to Alice.’

  ‘Maybe. Or maybe he’s trying to cover his tracks . . . Ladies?’ Calling back to Rose and Alice. ‘I need to make some calls. Ada, are you all set?’

  ‘We’re good,’ she said. ‘Do what you need to do.’ A worried expression crossed her face. ‘This is giving me the creeps, Lil. Maybe you should leave this to the cops. Call Mattie and tell her about this.’

  ‘I think she already knows. She was the one who told me that they were investigating fraud. I think I’m just catching up.’

  ‘No.’ Ada persisted. ‘Someone killed Delia, lit fire to a building with six hundred residents and God knows what else. Lil, I’m worried. We have to be careful. Whoever’s behind this is not fooling around.’

  Lil felt her fear, and realized she was right. The rational part of her mind was saying – this is none of your business, this is dangerous. ‘I want to find out what happened. I need to.’

  Ada gave a crooked smile. ‘I know. And you want to be the first with the story.’

  ‘Yes.’

  ‘Good. So how can I help?’

  EIGHTEEN

  Kyle Sullivan gave a weary smile to the Latina cleaning woman as she exited the fourth-floor conference room in the Safe Harbor Pavilion, aka the Alzheimer’s and dementia building. Inside were law-enforcement agents, four in suits and the tall silver-haired local Chief of Police. Next to him was a short woman in a navy suit, whom he recognized from after the fire.

  He watched the cleaning woman as she headed down the hall and felt badly for her; she was probably out of a job having worked in the now uninhabitable central residential building. Several brief conversations with the facility’s HR director, Frank Stillman, had left him confused, angry and scared. As the only available member of Nillewaug’s executive team Stillman – from Kyle’s perspective – had largely thrown up his hands. ‘How am I supposed to know?’ he’d told Kyle after one of the other nurses had asked if there’d be paychecks on Friday. And how the hell, Kyle mused, did this land on my shoulders? He pictured his glamorous sister, Kelly. She’d make some quip about his bleeding heart and ‘God-given right to save the world, while simultaneously making yourself miserable. You’re a fucking saint, Kyle,’ she’d say. ‘One of the last good guys . . . and we all know what happens to them.’ And she’d mime a gun to the side of her head and pull the trigger.

  The cleaning lady stood by the elevators. As she got in, their eyes connected briefly; she shrugged. He wondered what her name was, having passed her countless times over the last five years. He didn’t know it, and wondered if that made him racist – maybe a little. He thought back through all the hospitals and health-care facilities he’d worked in, first as a trainee, then as a registered nurse, and now as a nurse practitioner. How many cleaning and hospitality women had he passed, most of them with skin darker than his or with thick accents from Eastern Europe. While rarely discussed, there was tremendous institutionalized prejudice in health care, where almost all the top jobs went to white men, and up until a few years ago nursing was for women. And again old conversations with Kelly played in his mind. ‘Become a doctor for God’s sake. They’re the ones with power. Why would you become a nurse? It’s kind of a faggy thing to do Kyle, do you have something else you want to tell me?’

  ‘No Kelly, I’m not gay.’ Beyond that, there was no point in trying to explain something she’d never understand. Yes, he could have gone to medical school, but nursing, actually taking care of people – physically, emotionally, even spiritually – was what he’d always wanted to do. But now, running on two hours sleep since Saturday, he was less certain.

  There was more, too, as he stared at the closed conference-room door; an almost unbearable anxiety. So much that needed to be done. The phone hadn’t let up since the fire, and he felt a crushing guilt at having put it on the answering machine last night. He’d pleaded with both of the night nurses to take incoming calls. ‘Are you kidding?’ one had responded, and the other had clearly stated: ‘Sorry, not my job. And not yours either, Kyle.’

  The door opened and a tall young woman in a gray suit appeared. ‘Mr Sullivan, we’re ready.’

  Kyle followed her into the familiar room, with its brass-edged walnut table and comfortable mauve chairs. The vertical blinds were cracked open letting in a soft light.

  He was shown to a chair in the middle of the long side of the table facing the windows. Across from him were two men, one black, one white, both with close-cropped hair and dark suits. To their left was the short, curly haired detective he’d seen the morning of the fire and her tall partner. Grenville’s uniformed Chief of Police was at the other end. In the corner at a forty-five-degree angle from him was a youngish man with a camera on a tripod. Introductions were made, and as Alice had taught him as a child, he repeated each name as he shook their hands – ‘Agent Fitzhugh, Agent Connor, Detective Plank, Detective Perez, Chief Morgan’.

  Not knowing what to expect, Kyle reassured himself: just tell the truth and then you can get back to work.

  Detective Perez nodded to Agent Connor and began. ‘Mr Sullivan, how long have you worked at Nillewaug?’

  ‘About five and a half years.’

  ‘And you’re a nurse, correct?’

  ‘Yes, I’m an APRN.’

  ‘And that’s a special type of nurse?’ she asked.

  ‘I’m able to do things an RN can’t.’

  ‘Such as?’

  ‘Prescribe medication, prescribe certain treatments, as well as do everything that an RN is able to do.’

  ‘How is that different from being a doctor?’ she asked.

  Kyle met the short woman’s gaze. ‘It’s not so different. The scope of what I can do is not as extensive and there are certain medications I’m not allowed to prescribe.’

  ‘But you need to practice under the auspices of a physician, correct?’

  ‘No,’ he said, having explained the vagaries of his licensure many times. ‘In Connecticut the statute merely states that there’s a collaborative relationship with a physician.’

  ‘Interesting,’ Detective Perez said, and proceeded to get his background information, and where he trained. ‘So if you grew up in Queens and went to school at NYU, how is it you ended up at Nillewaug?’

  ‘Nillewaug had placed an ad in The Times, specifically looking for APRNs. It seemed like a good opportunity, plus I’ve always been drawn to geriatrics.’

  ‘Your grandmother is a resident here?’

  ‘Yes, Alice Sullivan. She’s a lot of the reason I decided to work here.’ Remembering how Kelly had found the ad in The Times jobs section. One of the few times she’d actually shown an interest in his career. Although he suspected it had more to do with Alice’s rapid decline and Kelly’s
fear that it would impact her lifestyle. ‘Alice has Alzheimer’s and there was no way I’d ever place her in a nursing home. I know too much about those places and I couldn’t do that to her. When I called Nillewaug for information about the positions they were very eager to have me interview. They use APRNs almost exclusively here.’

  ‘Instead of physicians?’ Agent Connor broke in.

  Kyle’s anxiety pinged, was something about this wrong? ‘More like in addition to. We do have a medical director, Dr Stanley, and then various specialists come as needed.’

  ‘What about Dr Trask?’ Connor asked.

  ‘Who . . .? You mean the man who died in his apartment? He was just a resident.’

  ‘Then why,’ Connor continued, ‘would he be signing treatment plans for other residents?’

  Kyle met Connor’s gaze. ‘I don’t know about that.’ He paused, trying to think through the mountains of biannual treatment plans and quarterly updates he’d written over the past two and a half years at Nillewaug. ‘I’m reasonably certain that all the treatment plans, at least the ones I’m aware of, were signed by Dr Stanley.’

  Connor made a note on his yellow legal pad. ‘Did Dr Stanley actually see every patient?’

  ‘No,’ Kyle said, knowing that he and the other two APRNs did the intake evaluations and ongoing treatment.

  Connor made eye contact with Kyle. ‘Did he see any of the patients?’

  Kyle was startled at the direction of Connor’s inquiry and answered truthfully: ‘I don’t know.’ It was a moment of clarity, like a curtain thrown open. Did Doctor Stanley see any of the patients? Throughout nursing school, and in his job as a visiting nurse before Nillewaug, he’d never questioned the crushing bulk of daily paperwork. He knew that his bosses cared more for the thorough and timely completion of forms than they did for the quality of the care provided. Never once had he been criticized for his handling of a case, but should a box go unchecked, or a diagnostic code be missing from a billing sheet, there would be someone insisting he correct the deficiency before shift’s end. Even more than that was the necessity that every treatment plan be signed, following a statement that the care provided was deemed ‘medically necessary’ by a physician.

  Connor clicked his tongue against the inside of his mouth. ‘Did you ever see Dr Stanley with a patient?’

  ‘No.’ And over the next fifteen minutes Kyle answered questions about how treatment plans were left in Dr Stanley’s mailbox. He’d come in two or three times a week, sign them and leave. On occasion Kyle would call Dr Stanley about a particularly worrisome case. He was always cordial, but those brief discussions left him with the sense that he was annoying the man who invariably told him to follow whatever course he felt best.

  ‘And you just worked in this building? The Alzheimer’s unit?’ Connor asked.

  ‘Here and the long-term care and rehab building – Maple Creek.’

  ‘But not the residential complex?’

  ‘No, that’s not a skilled facility. I would have no reason to be over there, other than visiting my grandmother.’

  ‘How much money do you make a year, Mr Sullivan?’ Connor asked.

  ‘Somewhere around a hundred thousand,’ Kyle answered, and then added: ‘I do a fair amount of overtime.’

  Connor nodded. ‘Why is that? Do you need the money for something in particular?’

  Kyle felt a tingle down his spine. Have I done something wrong? ‘They’re always short on nurses.’

  ‘And your expenses are considerable, aren’t they Mr Sullivan?’ Connor asked. ‘The monthly fees for your grandmother are over three thousand dollars.’

  Kyle looked at Connor, his face unreadable. Behind him his tall partner was now standing, staring at him. These are traps, he thought, the realization causing him to pause. These two federal agents knew how much money he made and also knew what his expenses were and were not. ‘I don’t pay monthly fees,’ Kyle said. ‘When I came to work here it was mostly because I was looking for a place for my grandmother. They cut me a very good deal. I didn’t think there was anything wrong with it . . . I still don’t.’

  ‘What was the deal?’ Connor asked.

  ‘We could buy in at a much reduced rate for one of the smaller units and they’d waive the monthly fee. In exchange I signed a five-year contract. The other two APRNs made similar agreements.’

  Connor nodded. ‘Those are tremendous perks. What would you say they’re worth?’

  Kyle remembered the relief he’d felt after that first meeting with Delia Preston and Kayla Atwood. They’d clearly wanted to hire him, and Delia knew why he wanted the job. ‘We’ve got your grandmother covered. There’s nowhere else she’ll get better care. Literally, this is the best assisted-care facility in Connecticut, probably New England. The food is great. It’s a secure facility, and as her dementia worsens, it’s nothing we can’t handle. Plus –’ and the look she’d given him, as though reading his every thought – ‘you’ll be here. It’s a win win. We get a dedicated and caring APRN and you get a wonderful place for your grandmother to live.’ At the time he’d felt relieved and grateful. The salary was nothing to write home about, and the other benefits were barely at par, but this . . . ‘It’s worth a lot,’ he finally said. ‘And I’m not just talking about the money. But let’s see . . . the fees would have been around three grand a month and one-bedroom units have a buy-in of two hundred fifty thousand and up.’

  ‘What did you pay for the unit?’ Connor asked.

  ‘A hundred . . .’ And beating the agent to his next question: ‘They let me finance it over five years. And there was wording in the contract that the discounted one hundred and fifty was a loan that would be forgiven over the course of five years. There was a progressive schedule, where each year a larger amount was subtracted. But if I left before the contract was up, I’d be responsible for the whole thing.’

  ‘That’s a strong incentive to stay.’ Connor cracked the barest of smiles.

  ‘You’re not kidding,’ Kyle agreed. ‘But I didn’t mind. It seemed like a Godsend.’

  ‘And you never asked yourself why they were cutting you such a good deal?’

  Kyle shook his head. ‘No, there’s a nursing shortage, this place has always struggled to keep its nurses and APRNs, and, considering what they were asking me to do, it was a great deal, but not suspicious, if that’s what you’re getting at. They get every cent out of me they put in.’

  Connor looked at the short female detective, and, like players passing a ball, she asked the next question. ‘Why don’t nurses stay?’

  ‘These are tough jobs, and because we’re always understaffed there’s an expectation that people will work doubles, like I did the night of the fire.’

  ‘Someone called out?’ she asked.

  ‘Yes.’

  ‘Can’t you refuse to come in?’

  ‘Theoretically, yes. In truth, someone has to be here.’ This is the part that kicked his guilt high. ‘That night I was the only nurse on duty for Safe Harbor and Maple Creek.’

  ‘That seems a lot,’ she commented.

  ‘It is. That’s why nurses don’t stay. In the time I’ve been here I don’t think they’ve ever had a full roster. I was supposed to cover one hundred beds that night in two separate buildings.’

  ‘Is that even legal?’ she asked.

  ‘I don’t know,’ he admitted. ‘If the health department caught wind . . . there were two aides on, but still, even for third shift the ratio – at least the one they promise in their brochures – is never supposed to be higher than thirty to one, which is still high.’ As the words left his mouth, he realized why he hadn’t known about the fire. When his first twelve-hour shift had ended at eight, he’d been confronted with the not infrequent specter of a night trying to stay on top of one hundred nursing home patients. Admittedly most would be asleep, but in the Alzheimer’s unit there were always wanderers and a couple of screamers. He’d not seen the fire, because he’d never had the chance. When he�
�d finally heard that first siren, he and an aide had been attempting to clean and then coax a wiry and incontinent ninety year old back to her room.

  To Kyle it seemed the questions would never end. As Detective Perez finished one line, Agent Connor would pick up the next. At one point he looked down to find a cup of coffee, and several times he thought about the work piling up for him, and whether or not anyone would show up for next shift, and what would happen if they didn’t? What would happen if he just left? The Nillewaug Promise had been broken. Alice had nowhere to live, and the kindness of those two women would surely reach an end. And then he thought of the spreadsheet on his computer, with the names of all six hundred Nillewaug residents in the burned building. Finally, all of them accounted for and the information passed along to the Red Cross, the Health Department and most importantly to their families. As he entertained the fantasy of walking away from Nillewaug, maybe taking Alice and going back to New York, he knew that wouldn’t happen. Yes, the fire was out, but six-hundred people in need of assisted living were homeless. The immediate disaster was passed, but in its wake was something larger. As the questions shifted from one direction to the next, he was forced to confront painful truths. The worst of these was brought home by Detective Perez, whom he sensed had first-hand knowledge of the struggles he’d gone through with his grandmother.

  ‘Help me to understand this,’ she began. ‘Your grandmother has fairly advanced Alzheimer’s?’

  ‘Moderate, not advanced.’

  ‘But still . . . why would they have agreed to take her into the assisted-care residence when what she required was something higher? You said earlier that she needed a nursing home.’

  ‘I didn’t want them to know how bad it was,’ he admitted.

  ‘So you lied?’

  ‘I did, but she still dresses herself, takes care of her hygiene. Obviously she can’t cook or handle a checkbook. But when I saw how much support they had in place, it seemed doable.’

  ‘Your grandmother wasn’t the only one, was she?’