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Understaffing at rehab center contributed to ex-legislator's death, family says

Family members of former state lawmaker Herschella Horton — devastated by her death last month — have filed a complaint alleging inadequate care at a local rehabilitation center contributed to her demise.

Horton’s son, Jon, and her daughter, Cheryl Walker, say their mother was recovering well from spinal surgery at St. Joseph’s Hospital, but that changed after she was transferred to Sabino Canyon Rehabilitation & Care Center, 5830 E. Pima St.

“She was a fully functioning person before surgery, she was recovering well in the hospital but, when she went to that facility, all of that stopped,” Walker said in explaining why she has asked the Arizona Department of Health Services to look into what happened.

No one with the center responded to Arizona Daily Star interview requests which included several phone calls as well as emails.

Staffing shortage

Walker and her brother said understaffing seemed to be a big part of their mother’s decline at the rehabilitation facility.

Horton needed assistance getting to the bathroom, but there wasn’t enough staff on hand to help, Walker said. Their mother needed physical therapy, but no one came in to provide it, Walker said.

Horton had one occupational therapy session on the Monday before she died, Walker said, but that was the only therapy she received in her four days there.

Most of Arizona’s skilled nursing home and rehabilitation facilities have experienced staffing shortages in the past couple of years, said Tom Herrmann, a spokesman with the DHS.

Both state and federal regulations require that a facility needs to have enough staff to meet the needs of the residents, he said, and federal regulators are in the process of coming up with mandatory staffing ratios, but there is no expected date for that to be announced.

Surgery for back pain

Horton was born in Lawrenceville, Illinois, and obtained a nursing degree in 1960. She lived in Tucson for more than 60 years and earned a management degree from the University of Phoenix.

She was first elected to the Arizona House of Representatives in 1989 and served five two-year terms, focusing on issues such as health equity and the environment.

Walker said her mother, 83, was still politically active and living independently but had recently started having more serious back pain. The surgery was to help with spinal stenosis.

“I went with my mom to meet with the surgeon,” she said. “He said: ‘You’re in perfect health. Your bones are degenerating due to age, but you’re in good health otherwise for me to do the surgery.’”

Horton’s son lives in the Netherlands and flew here the day after her surgery, arriving Tuesday, April 26.

The surgery a day earlier was a success, her children said, and Horton was cleared for release that Friday. However, her children asked to keep her there one more day to be sure, and so she was moved to the rehabilitation center that Saturday night, April 30.

On Sunday, May 1, Walker said she was shocked to find hardly any staff on site to attend to her mother’s needs. Walker and her brother stayed there all day, concerned but not sure what to expect.

That night, after they left, she fell out of the bed, and her children, concerned because she had just had surgery on her neck, said it was unclear who checked her condition afterward.

“We were told she’d been checked out and was fine, but we could not get any more of an answer than that,” she said.

Their mother was not eating or drinking enough. They believed that was partly because the surgery had left her with a sore throat and also, they thought, because she was being distracted by increasing hallucinations.

“When they transferred her to the Sabino Canyon rehab center, they did not put her on an IV,” Jon Horton said. “My sister and I are spending eight or nine hours a day with my mom, and that’s the first thing I notice when she’s moved, that they don’t have her on an IV.”

Jon Horton said staff told him that when she became thirsty, she would drink.

“I said, ‘No, you need to use an IV,’” he said. “I knew something wasn’t right, but then kept thinking, ‘This is their job, this is what they do. Maybe you’re overreacting.’”

On Monday, May 2, more staff were there, and it was suggested that a urinary tract infection might be causing the mental unsteadiness. A urine sample was ordered, but no one ever got one.

Tuesday went by without much change, her children said, except their mother’s hallucinations were getting worse.

“By Tuesday evening, my brother and I were like, ‘Something has to change,’” she said. “We could see her rapidly declining.”

When Walker arrived at the rehab center on the morning of May 4, she told them she needed to talk to a doctor right away.

“I said: ‘Either send in the doctor, or I am going to sign her out of this facility. You are not providing the care that she needs.’”

Facility cited

Another death at the facility in February 2020 led to state sanctions after the resident, who is not named in the state record, bled excessively after having several teeth extracted.

The center was cited for “failing to ensure that policies and procedures for physical health services were implemented” and not reporting a neglect allegation within the two-hour window required under state guidelines.

The state’s DHS also found the staff did not notify the resident’s doctor quickly enough about the resident’s change in condition.

A complaint filed in April 2020 shows the resident had been taking a blood thinner called Coumadin and that this resident’s teeth were extracted without going off the medication, which is a critical step to prevent excessive bleeding.

“In addition, the facility nursing staff neglected to inform the physician that the resident (who received daily Coumadin) had just had multiple teeth extracted and continued to bleed until the afternoon of the next day which was more than 24 hours of oral bleeding,” the record reads.

The resident received multiple blood transfusions at a hospital two days after the dental procedure before dying Feb. 8, 2020.

Records lacking

Cheryl Walker picked up the medical records from her mother’s time at the facility and was perplexed there was nothing in there about her death, nothing to help her answer some of her agonizing questions.

Her cause of death on the death certificate was listed as a cardiovascular event, and no autopsy was ordered.

On that Wednesday morning, May 4, less than 12 hours before Horton died, her children again requested that they start IV fluids. Walker said she told them that if the facility would not accommodate their request, they wanted to move their mother back to the hospital.

Finally, that afternoon, an IV was started.

A nurse practitioner was able to get a urine sample and, Horton’s medical records show, she was actually holding over 600 milliliters of urine in her bladder and not expelling it.

“Within those few hours, Jon and I could see a slight improvement,” Walker said. “She was talking to us more.”

Then their mother requested her favorite ice cream, and Walker rushed out to get it.

“My sister and I left that evening crying in the parking lot, saying, ‘Thank God, she’s OK now,’” Jon Horton said.

About an hour later, around 6:30 that evening, they received a call: their mother was unresponsive, and paramedics were on the way.

“Her heart just stopped,” he said. The paramedic “brought her back several times, but she couldn’t maintain it.”

Contact reporter Patty Machelor at 806-7754 or

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