(Memphis) There are new and disturbing details about a local home health agency and one of its nurses, who is charged in connection with her patient's death.
The On Your Side investigators uncovered what appears to be a pattern of problems for Where the Heart Is.
We obtained a copy of a 93-page report from the Tennessee Department of Health. States are contracted to conduct surveys of home health agencies and nursing homes on behalf of the federal government.
A survey dated October 26, 2012, outlines what happened before and after 3-year-old Kayla Andrews died.
From no training to ignoring doctor's orders, it reveals Kayla's nurse, Demequa Bonds, and other employees at Where the Heart Is, consistently put their patients' lives in jeopardy.
We sat down for a one-on-one interview with Kayla's mom, Christina Andrews, the day after the one-year anniversary of her daughter's death.
"My daughter was a fighter from day one."
In fact, Andrews says it was a battle just to give birth to Kayla and her twin sister Sarah.
After her son Charlie, Christina suffered multiple miscarriages, and even had an ovary removed.
Then came the miracle of two.
Kayla was born with a rare disorder called Moebius Syndrome.
"My daughter was unable to make facial expression, she could not move her eyes side to side, she couldn't smile, she couldn't suck," explains Andrews.
Kayla also required 24/7 care. She was on a ventilator most of her life, had a tracheostomy and was fed through a tube.
However, Andrews says her daughter was slowly making progress.
"She had just gotten a new wheelchair, she had just gotten a new bed, her big girl bed."
Kayla was even starting pre-school with a home-bound teacher.
Andrews also began taking college classes in hopes of one day pursuing a law career to help people with disabilities.
Unfortunately, this new chapter never started for the Andrews' family.
"I kissed my daughter and I spent some time talking to the nurse, I got ready for bed and she was gone, five hours later."
Kayla's trach had come out and her nurse couldn't get it back in.
She and Andrews did CPR, but Kayla was gone.
"Do you feel like something went wrong that night?" I asked Andrews.
"I know something went wrong that night," she replied.
Andrews won't say much because of the pending case, but the On Your Side investigators uncovered disturbing details in a report from the Department of Health.
In the report, Andrews told investigators Bonds seemed "incoherent" and didn't know how to perform CPR.
She also said she woke up hearing Bonds screaming, "I killed this baby!"
"I still have nightmares and flashbacks about that night," Andrews told us.
According to the report, Where the Heart Is didn't do an investigation after Kayla's death.
In fact, no one even contacted Andrews.
Furthermore, Bonds admitted the agency never trained her on using the ventilator, trach or a pulse oximetry machine, which she silenced the alarm to, the night Kayla died.
The agency's Director of Nursing states in the report that, when asked if all staff members' skills were observed, "No...just went by the trach test and questionnare."
The DON told interviewers employees' skill levels were not identified by direct observation.
The report notes a telephone interview conducted with Bonds on October 26, 2012, to explain what happened the night of August 27th.
Bonds, identified only as Employee #15 in the report, went on to explain that she had been cleaning the room.
She said Kayla (identified as Patient #11) had "popped the trach out" a few times during her shift.
Bonds says she often silenced the alarm on the pulse ox machine so it wouldn't wake Kayla's sister or Andrews.
She said the trach came out, she did have lubricant and couldn't get it back in.
She says she "called for mom" and started CPR.
At some point, Bonds said Andrews took over CPR while she went to get Mr. Andrews.
In the report, Andrews says she was the one who started CPR.
The report also reveals a number of deficiencies related to other patients besides Kayla.
The survey outlines deficiencies that put patient's health and safety at risk and presented "immediate and serious" threats and "immediate jeopardy" as well as "risk for potential death."
The On Your Side investigators contacted Where the Heart Is.
We spoke to Administrator Sam Overbey who referred us to their attorney, who said he couldn't comment.
A spokesperson for the Department of Health says Where the Heart Is corrected all of the deficiencies found in the October 2012 survey as well as subsequent surveys.
The agency was at risk of losing its license to operate.
Unlike nursing homes, there are no fines for home health agencies.
Andrews is still taking college classes and wants to be an attorney. She says she's just not quite as sure of her path without Kayla.
However, Andrews refuses to give up the fight for Kayla. "She always had this look in her eyes that said don't give up on me."
Just before Kayla died, Andrews began advocating for what's called Katie Beckett waivers.
They allow families to get additional help from the state, no matter their income.
Andrews quit her job, so the family could make less money and qualify for home health care for Kayla. More than 20 states currently allow such waivers, including Arkansas and Mississippi.
Tennessee does not.
Andrews said, "It amazes me, she was only three and a half years old and she was never able to smile, but not one single person that met her walked away without a smile on their face."
By sharing their story, Andrews says Kayla's legacy lives on.
"She was an amazing little girl and she changed my life from the moment she was conceived. 20 years from now, I want to see her still changing people's lives."
We also reached out to Demequa Bonds. A person who answered the phone said she was out of town. Bonds has a hearing scheduled for September 19th.