Patient Suffers Fatal Fall in VA Nursing Home


A 91-year-old World War II veteran died from his injuries after suffering a fatal fall in his Iowa-based VA nursing home.  The victim’s family believes that caretakers at the Veterans Affairs (VA) nursing home were negligent, and that the level of care their loved one received is the reason why he died. 

Administrators at the nursing home say that staff members reacted appropriately.  Surveillance videos, reports of what happened, and records of previous negligence at the nursing home raise questions, however. 

Veteran Resident Background

James “Milt” Ferguson Sr. served in the U.S.  Navy in World War II.  He survived one of the most gruesome wars the world has ever seen and returned home to work in the newspaper business for more than 20 years.  In his advanced age, he developed dementia and was diagnosed as legally blind. 

His family was no longer able to provide him the round-the-clock care he needed, and so his son made the very difficult decision to place his father in a nursing home.  As a veteran, Milt was entitled to a place in a VA nursing home.  His placement in a VA home should have offered comfort and peace of mind for his family.  Instead, it resulted in a nightmarish situation.   

When Mr.  Ferguson entered the VA nursing home, he already had a diagnosis of dementia.  During his time as a resident there, his condition deteriorated.  A downturn in his mental status resulted in his being transferred out of the VA nursing home into a VA Medical Center to receive care from a VA psychiatrist.

A little more than a week before the fall, Mr.  Ferguson was placed under one-on-one observation with an aide while his doctor adjusted his medications.  His struggles with dementia made him a danger to himself and to those around him, as he would frequently wander around in an agitated state.

When he returned to the VA nursing home, he no longer had strict monitoring, despite his continual wandering the halls of the facility and into other patients’ rooms.   His agitated behavior was immediately apparent, once again, after he returned to the nursing home with no dedicated aide to monitor his behavior.

VA Nursing Home Fall Information

The events leading up to Mr.  Ferguson falling and injuring himself appear to begin with his wandering in the hallway of the facility unsupervised.  Surveillance video shows Mr.  Ferguson in his wheelchair, wheeling himself into the hallway and then into another resident’s doorway.  The next thing visible on the video is Mr.  Ferguson falling over backward in his wheelchair, striking his head against the floor.

It was reported that the other resident shoved Mr.  Ferguson’s wheelchair out of the doorway, which contributed to the chair tipping over.   After the impact, Mr.  Ferguson is seen laying on the floor in an awkward position with the wheelchair.  A short time passed before two nursing home staff members came into the frame.  Several more minutes passed before they attempted to lift him from the floor and put him back in his wheelchair.

According to the timestamp on the security video and an incident report submitted by the staff members who helped Mr.  Ferguson after his accident, an unbelievable 40 minutes elapsed between the time the injury occurred and the time that staff members reported the incident to their superiors.

Two more hours passed before the victim saw an emergency room doctor.  With a traumatic head injury, Mr.  Ferguson remained in an emergency department for two-and-a-half additional hours before being transferred to a trauma hospital.  That is a total of five hours that elapsed between the time his head hit the floor and when he received treatment in an appropriate facility.

The next day, Mr.  Ferguson – a man who served our country – died from the traumatic head injury he sustained.  A head injury that could have been prevented had the nursing home staff been properly supervising residents. 

A Family Outraged

Watching the security video of the injury that eventually took his father’s life the veteran’s son, Jim Ferguson, told USA Today that he,” …broke down”.  Discussing his decision to place his father in a VA nursing home, Mr.  Ferguson said he made the choice because he knew his father needed constant monitoring that he himself could not provide.  He said that someone should have been watching his dad. 

Further, more should have been done after the accident took place.  Mr.  Ferguson stated that

“It’s like my dad died at their hands.”

He has retained an attorney and is pursuing legal action in connection to the VA nursing home’s failure to keep his father safe.

What are the Standards of Care in Nursing Homes?

The traumatic head injury that caused this veteran’s death was preventable.   His caregivers failed to provide a safe living environment suited to the needs of his condition – namely his dementia.  He demonstrated a predictable pattern of agitated behavior.  There was every reason to believe that he would continue to be a danger to himself and to other nursing home residents.

The standard of care for patients with dementia in such an advanced state is close, if not constant, monitoring in order to protect patients and others around them.  There should have been orderlies, certified nursing assistants (CNAs), or other staff members available to prevent Mr.  Ferguson from wheeling himself around freely in the facility.  Truly, it was only a matter of time until Mr.  Ferguson hurt himself or someone else.  The nursing home failed him greatly in this regard.  They failed to keep him safe.

For all nursing home patients, receiving the standard of care means that staff members must identify patient needs based on their cognitive conditions or medical diagnoses.   Providing the standard of care means VA nursing homes must provide for the needs of patients with these types of cognitive deficits and mitigate the risks of the aggressive behaviors associated with them. 

Is Care worse in VA nursing homes?

There is some indication that nursing home residents in VA nursing homes are subject to substandard care, more instances of abuse, and have generally lower qualities of life than residents in private nursing homes.   USA Today reported in March 2019:

  • More than half of VA nursing homes inspected by a private contractor had conditions that caused actual harm to veterans,  including inadequate supervision for residence or  hazardous conditions.  
  • 70 percent of VA nursing homes scored worse in safety metrics than privately owned nursing homes, including instances of bedsores and infection.
  • During a surprise inspection, the VA nursing home where Mr. Ferguson resided was found to:
    • Employ staff members who treated residents without respecting their dignity.
    • Failure to meet basic sanitary standards.
    • Failure to follow infection containment procedures.

A Problem that Breeds Neglect

Families make the call to place their loved ones in nursing homes as a trade-off.  They are no longer able to care for their elderly family members, but in that environment, nursing home residents ought to have the benefit of access to skilled nursing care and monitoring.

The sheer amount of time that passed between the moment of Mr.  Ferguson’s fall and when he received appropriate treatment for his traumatic head injury indicates that there were too few skilled care workers present in the VA nursing home for him to receive the care that he needed.  Not only did the facility fail to monitor him appropriately to prevent him from getting hurt, but when he fell, they failed to react in a timely manner, which could have saved his life. 

Unfortunately understaffing is a massive problem in nursing homes across the country.  The problem is rampant in VA nursing homes and privately run nursing homes.  With an eye on the bottom line, nursing home administrators schedule too few workers to adequately provide for the needs of residents. 

Taking the Fight to VA Nursing Homes

It is a common misconception that VA hospitals and VA nursing homes are immune to lawsuits.  Veterans and their families who experience healthcare negligence in a VA setting do have options.  Although it is true that this area of law is exceedingly complicated, these hurdles present no problem for our attorneys.  At Nursing Home Abuse Center, we can help nursing home residents and their families understand and protect their legal rights. 

If you or someone you love has suffered substandard care, abuse, or neglect while in a VA nursing home, contact Nursing Home Abuse Center to speak with one of our nursing home abuse lawyers.  Submit our contact form or call 1-800-516-4783 to schedule your free consultation.


meagan cline

Written By Meagan Cline

Meagan Cline is a professional legal researcher and writer. She lends her expertise to FNHA and our websites, including Birth Injury Guide and