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Nearly three months after an 85-year-old veteran died after being scalded in a whirlpool bath at the Claremore Veterans Center, the executive director of the Oklahoma Department of Veterans Affairs has retired and the administrator of the center abruptly resigned.
A veterans affairs official said executive director Martha Spears retired Friday, citing her husband's ongoing medical issues. Claremore Veterans Center administrator Cynthia Adams did not give a reason for her resignation, said Larry Jordan, administrative programs officer at the Department of Veterans Affairs' Claremore division.
Neither Adams nor Spears could be reached for comment.
The War Veterans Commission, which appoints the department's executive director and administers veterans programs in the state, has set an emergency meeting Tuesday in Oklahoma City.
Family members of the man who died, Jay Minter, as well as family of others who have been at the Claremore facility say this is not the first instance of neglect or abuse at the center. A state legislator has created an interim study to review the Department of Veterans Affairs.
Minter's widow, Frances, said she wants people to know about what happened to her husband, whose death was first reported by The Journal Record.
"I'm hoping that through the death of my husband there will be some changes to the system and this never happens again to anybody," she said in an interview with the Tulsa World.
She has filed a tort claim against the Department of Veterans Affairs. The Rogers County district attorney is not filing charges in the case.
An investigation of the incident by the Department of Human Services Adult Protective Services Division substantiated claims of caretaker abuse and caretaker neglect, noting that multiple whirlpools at the center lacked working temperature valves and that employees failed to notify a physician of the injuries or take Minter to the emergency room.
An internal investigation by the Department of Veterans Affairs identified willful negligence and abuse by one nurse and neglect by three additional employees.
A death summary by the center identifies the immediate cause of death as arteriosclerotic cardiovascular disease with thermal burns as a contributing factor. That is at odds with the medical examiner's report, which lists complications of thermal injuries as the cause of death.
The documents were obtained by the Tulsa World but not released by their respective agencies. Officials with the Department of Veterans Affairs declined to comment further.
The physician assistant who was on call the night of the scalding -- who is also Adams' husband -- announced he was retiring June 1, according to the Journal Record.
Jay and Frances Minter grew up together in a small-town in New Mexico, where their families would attend the same ice cream socials.
Jay Minter was drafted when he turned 18 and served for two years in World War II.
One of his duties during the war was to pick up dead bodies and put them on a truck.
"It was pretty traumatic for him," Frances Minter said.
When he returned from the war, they started dating and were married June 20, 1950.
He suffered from post-traumatic stress disorder, although it wasn't diagnosed until 1992.
By the time he was at the Claremore Veterans Center, he also suffered from Alzheimer's disease, dementia, diabetes and a host of other illnesses and conditions. He was admitted in April 2004.
Documents show that on May 2 at about 4 p.m. Jay Minter was given a bath in a whirlpool that was apparently hotter than the federal guidelines of 115 degrees Fahrenheit.
The nurse giving him the bath said she knew the tub's thermometer wasn't working but she felt the water with her hand and didn't think it was too hot.
The nurse, who was working an overtime shift, was solely responsible for four residents in the bathing area.
An investigator later ran the whirlpool and measured the water at 127 degrees.
When Minter got out of the bath, nurses noticed a skin tear on his thumb and skin peeling on his heels. His skin was staying red an unusually long time.
The nurses notified the physician assistant who was on call and took Minter back to his room. They cut off his pants and saw first- and second-degree burns covering his arms and the lower half of his body.
He was not taken to the emergency room.
Nurses told investigators that Minter did not cry out or appear to be in pain, but his wife said he called out to her when she entered the room and said he had been burned.
Their daughter, Kay Deal, arrived soon after he was taken back to his room.
"He was very alert and he was in severe pain," she said.
Ten hours after getting into the whirlpool, Minter was dead from what the medical examiner's report would later call complications of thermal injuries.
Minter's doctor was not notified of the incident until the next morning, after Minter had died.
Employees at the center told investigators they asked Frances Minter whether she wanted her husband to go to the hospital and she said no.
Frances Minter said she did say they should try to treat him at the center, but never said he shouldn't go to the hospital. She said the decision should have been up to a medical professional, anyway.
"For me to be blamed for that, it was just appalling to me," she said.
Employees said Frances Minter was concerned about the cost of taking her husband to the hospital, but she said money issues would never keep her from getting the proper care for her husband.
She said the center doesn't have enough staff to adequately care for all the residents.
"The problem is that they're pushing these people too shorthanded and they are stretched like rubber bands beyond their limits," she said.
Frances Minter alleges that the last incident at the Claremore Veterans Center was not the first for her husband. She says one employee called him by a profane name and later pulled on his chest hairs.
That employee was transferred to another floor, she said.
The family of another World War II veteran, Allan Kraft, also has filed a tort claim against the Oklahoma Department of Veterans Affairs, the Oklahoma War Veterans Commission and the Claremore Veterans Center.
They say Kraft was unnecessarily restrained physically and chemically and made to sit in his own waste for extended periods of time. He was involuntarily discharged and removed from the center in October, seven months after his admission.
Kraft's son, Michael, said long-term care in Oklahoma "is a horrible situation."
Kraft has been to 10 facilities and his son is still not convinced he's getting proper care. He and his sister spend hours each day with their father to make sure he is being taken care of.
The family alleges in its tort claim that Kraft wasn't treated properly at Claremore Veterans Center.
"Dad was injured more severely by the VA than he was in eight months of combat in the second world war," Michael Kraft said. "And I think that speaks volumes."
The tort claim has been denied and a lawsuit is planned, he said.
Soon after Minter's death, Gov. Mary Fallin appointed eight new members to the Oklahoma War Veterans Commission.
A legislative study will examine the department's infrastructure, staffing and turnover at the veterans centers and the cases of abuse that have been reported, said Sen. Frank Simpson, R-Ardmore.
Reports of patient abuse must be investigated for the sake of residents who don't have family members to advocate for them, he said.
"We're going to take a look at the ODVA really from the top to the bottom," he said.