LEFT ON THE STREET
A homeless amputee, a good Samaritan and a flawed system
Leigh Bowie was walking to yoga when she saw the man slumped across a bus-stop bench near Christown Spectrum mall.
Bowie stopped to see if he was breathing. He was, and his name was Martin, she learned.
He had on shorts, two dirty T-shirts and no shoes. He smelled as if he hadn’t showered in weeks. A wheelchair stood nearby.
One foot was red and swollen. The other was wrapped in gauze that was black with grime and unraveling.
“I always check and make sure they’re OK,” said Bowie, 55, who directed nursing for years at a free Phoenix health clinic for the poor. “There’s often not a lot you can do, but I knew his dressing needed to be changed.”
It was no small wound. Half of Martin’s foot had been amputated.
Martin didn’t remember when or where. Bowie could tell he had problems with his short-term memory.
She bought him cheese sticks, orange juice and a chocolate bar at a corner store and considered next steps.
“I don’t know how he survived on the streets like that,” Bowie said. “Someone dropped the ball.”
As Bowie advocated for Martin in the weeks that followed, she was shocked by the reac-
“I am still in disbelief and can’t really believe adults are allowed to behave so badly.”
Leigh Bowie Good Samaritan who helped Martin
tion.
Doctors shrugged. Police officers kicked her out of a hospital. Legal guardians lost track of him. Hospital officials refused to share information. A court blocked her from managing his care.
An Arizona Republic investigation into Martin’s case revealed a number of institutions charged with Martin’s well-being dropped the ball:
❚ An overworked county agency and an unlicensed assisted-living center did little to prevent him from wandering the streets.
❚ At least two medical facilities apparently put him back on the street while injured, a practice known to Phoenix advocates for the homeless as “patient dumping.”
❚ The hospital’s refusal to share information delayed attempts to ensure his safety.
The consequences were serious: Martin’s leg had to be amputated again — to the knee.
Medical and government officials denied requests for documents and interviews to fully explain how a mentally impaired 67-year-old man ended up on a busy Phoenix avenue wounded, bandaged and abandoned.
The Maricopa County Public Fiduciary, his legal guardian for more than a decade, turned down a request by The Republic to speak with Martin. An interview would not be “in his best interest,” a spokesman said.
The Republic is not publishing Martin’s last name because he is a ward of the county.
“I am still in disbelief and can’t really believe adults are allowed to behave so badly,” Bowie said. “I’m talking about doctors, health-care professionals and police officers.”
She added: “There was no conceivable reason for this situation, except incompetence.”
‘Patient dumping’ on the rise
Homeless advocates worry cases such as Martin’s are increasing in Maricopa County as the homeless population swells. The county has seen a nearly 150 percent spike in people without shelter since 2014.
Patient dumping occurs when hospitals, psychiatric wards or other medical facilities discharge patients to shelters or the street without plans for their care, instead of keeping patients until they recover or transferring them to a nursing facility.
The practice endangers patients and burdens homeless shelters unequipped to handle serious health conditions, according to advocates.
Cole Hickman, intake coordinator for the downtown Phoenix Human Services Campus, said medical drop-offs occur regularly outside the shelter.
Last year, a hospital left a woman on the sidewalk and she began having a seizure after employees drove off, Hickman said. Shelter staff called the Fire Department to take her to another hospital.
“That’s a travesty,” Hickman said. “If someone is in that kind of condition, they should not be here.”
In another 2018 case, a psychiatric facility in Show Low transported a patient nearly 200 miles to the campus without calling ahead, Hickman recalled. The shelter was full, and the patient’s medical needs were too severe for shelter staff to handle.
“We argued with them for quite a bit, and they took (the person) back,” Hickman said.
Shelter employees have found patients wearing hospital gowns, colostomy bags and chest ports after heart surgery, he said.
The individuals arrive using wheelchairs or walkers, carrying bags of medication or oxygen tanks, advocates said. Some have cancer, diabetes or paranoia, or are blind. They are brought by taxi, Uber, government-funded medical-transport vehicles and even ambulance, Hickman said.
“They’re being dropped off to be put into an ambulance or taxi to go back a half-hour later,” he said. “That makes no sense.”
Hickman began documenting incidents in September.
Since then, medical facilities have brought 19 patients to the Human Services Campus without coordinating with staff, he found. Two patients were so unable to care for themselves that they were sent back.
More than half needed a walker or wheelchair, which some patients didn’t receive when they were discharged.
Roughly another 300 people who visited the shelter on their own last year reported they had spent the previous night in a hospital or psychiatric facility, Hickman found. Not all of the former patients had conditions unsuitable for the shelter, but the records don’t differentiate those cases, he said.
Patient dumping occurs “often enough to be frustrating, but not enough to pay a nurse to stand on the sidewalks,” Hickman said.
Some medical facilities wait until the last minute to plan discharges, he said, and frequently tell patients a bed has been reserved at the shelter, which is untrue.
“If they’re having this conversation with a patient at 3 in the afternoon, and they get to us at 5:30, after we’ve closed, that’s not good,” Hickman said.
At least two people in 2018 died in patient-dumping cases across the country, according to media reports.
After the Sacramento Bee revealed shocking examples, including a woman living in her car after a double mastectomy, the California State Assembly passed a law requiring safe hospital discharges for homeless patients.
Arizona has no explicit law banning homeless patient dumping.
Hospitals say they follow all regulations.
“In addition to complying with state and federal law, hospitals go to great lengths to ensure all patients, including those without permanent housing, receive the care they need,” the Arizona Hospital and Healthcare Association said in a written statement. “While we cannot comment on this case, it is standard practice for a patient’s decision making power to be assessed and for case managers to be assigned to patients who are determined to be high risk for homelessness.”
Bowie blocked from visiting
While Martin ate his snack, Bowie saw Abrazo Central Campus hospital across the street from the bus stop.
With Martin’s go-ahead, she wheeled him to the emergency room of the facility at 2000 W. Bethany Home Road.
A nurse administered fluids and pain medicine, Bowie remembered. Martin had no money or identification and couldn’t recall his address or phone number.
A physician assistant asked if Martin had finished antibiotics the hospital prescribed him two weeks earlier, Bowie wrote in notes she kept of the incident.
Martin had no recollection of the prescription, Bowie said. She was surprised by the questions.
“I would seriously like to know if either health-care professional thought for a moment that (Martin) was capable of obtaining the money needed to fill a script, capable of filling the script and then capable of taking his antibiotics as prescribed, all while living at the bus stop?” she wrote in her notes.
Bowie helped Martin remove soiled clothes, scrubbed layers of dirt from his hands and wheelchair, and got him a burger and fries, she said.
“It’s not McDonald’s, but it’ll do,” she remembered he joked.
Before Bowie went home for the night, Martin gave a nurse permission to provide Bowie with medical information about his condition, she said.
When she returned the next morning, Bowie was hoping to give Martin new clothes and a haircut.
Instead, hospital staff greeted her with hostility and Martin with indifference, she said.
One doctor shrugged when Martin said he was worried where he would go when he left the hospital, Bowie recalled. He told Martin he would be fine because hundreds of people have their leg cut off, she recorded in her notes.
When Bowie asked about Martin’s blood work, the doctor said she needed medical power of attorney, she recalled.
Patient privacy is protected under law, unless a patient authorizes someone else to receive information or a patient is unable to make health-care decisions and a relative or close friend “who has exhibited special care and concern for the patient” serves as their representative.
Bowie told the doctor she would work on it.
“He got very angry and said I was threatening him. And he stormed out,” she said.
An Abrazo Central case manager met with Martin, Bowie recalled. The woman gave him papers listing shelter phone numbers.
“This is obviously a gentleman that doesn’t have the faculties to help himself,” Bowie said. “He kept asking people, ‘Where am I going to go from here? I can’t go back to the streets.’ ”
A few minutes later, Abrazo Central’s risk manager — who coincidentally also serves as the hospital’s patient representative — appeared.
A security guard and a Phoenix police officer were in tow.
“Next thing I know, they said the patient didn’t want me there anymore,” Bowie recalled. “Whenever I asked him, he was perfectly fine with me being there.”
Bowie explained she was trying to help.
“If he doesn’t have a good advocate, who’s to say he doesn’t end up back on the streets?” Bowie said.
The police officer said she needed to leave.
Bowie went home flustered and angry. She called to check on Martin, but hospital employees denied he was there.
Abrazo Central had banned all attempts to contact Martin, the public fiduciary later learned. That decision would prevent Martin’s guardians from finding him for weeks.
Abrazo Central disagreed with Bowie about what happened but could not comment on Martin’s case because of privacy law, spokesman Keith Jones said. He declined to give The Republic a privacy release form a guardian could sign.
Circle the City offers help
There is a place Phoenix-area hospitals can safely discharge patients who are experiencing homelessness.
Circle the City opened in 2012 near Third Avenue and Indian School Road, with 50 beds for sick men and women needing a place to stay while they recover.
Last summer, the non-profit opened a second clinic with 50 beds at the Human Services Campus.
But the organization gets more calls for placements than it has openings, CEO Brandon Clark said.
“It’s a logic puzzle every day,” Clark said. “This is a need far beyond what we have a capacity to address.”
Although Circle the City tries to find alternatives when it runs out of room, Clark realizes hospitals seeking a safe discharge are in a bind.
“It’s difficult for us to bang on the table and say, ‘Why didn’t you refer this patient to us?’ ” he said. “We’re very aware of the fact that the word is out that it can be difficult to get patients into our program.”
Circle the City needs at least 200 beds to meet demand, Clark estimated. But expanding is difficult because reimbursements from hospitals, private health insurers, Medicare and Medicaid fail to cover about $1 million in costs per year for each 50-bed facility, he said.
Clark is trying to convince medical groups to invest more.
A three-year study by Brandeis University and the National Healthcare for the Homeless Council found patients who recuperated at Circle the City in Phoenix visited hospitals roughly 60 percent less afterward than they did before.
When people fully heal and get connected to housing and jobs at respite centers, they leave the streets and use emergency rooms less, Clark said.
Medicare and Medicaid saved nearly $5 million a year because of one 50-bed facility, the study found. The savings were more than enough to cover the annual costs of Circle the City expanding to its goal of 200 beds.
“If we could convince health plans or Medicaid to come up with that extra (funding) in reflection of the millions we’re saving them, we could ... grow medical respite to meet the needs of the community,” Clark said.
Until then, Circle the City is finding partners to expand in small ways. The non-profit A New Leaf has applied for a grant from Dignity Health to add five medical respite beds staffed by Circle the City at its Mesa men’s shelter, said Dana Martinez, New Leaf shelter services director.
“It gives them a safe place to be out of the elements, three meals a day and that opportunity to get healthy,” Martinez said. Many times, she added, “it’s just that one health issue that is keeping them from solving their homelessness.”
County was supposed to help
Getting kicked out of Abrazo Central didn’t stop Bowie from trying to help Martin.
She posted what happened on Facebook, contacted The Republic and filed court paperwork requesting emergency guardianship.
“My interest in this case is as a good Samaritan ... to ensure his safety and medical continuum of care,” Bowie told Maricopa County Superior Court. “He is in danger of being released from the hospital back to the streets, where his condition may deteriorate once again.”
Bowie didn’t know Martin already had a guardian: the Maricopa County Public Fiduciary.
The agency, which manages affairs for incapacitated adults whose family can’t care for them, took responsibility for Martin more than a decade ago.
Court paperwork illuminates the struggles he faced.
In the 1990s, Martin had a wife and two children, a four-bedroom house with a swimming pool in an upscale part of Scottsdale, and a steady plumbing job, The Republic learned.
But at some point, Martin was laid off and began drinking, court documents showed. By 2003, he had been charged with extreme DUI, was divorced and had landed in the hospital.
Family members declined to be interviewed by The Republic or did not return calls.
Doctors diagnosed Martin with alcohol-induced brain damage, a staph infection, life-threatening lung problems and an inability to care for himself for the rest of his life, according to documents.
“He cannot manage his own finances or health care,” the court records said. “He cannot make respon-
sible decisions concerning his person.”
Martin’s out-of-state father and brother placed him in a Phoenix assisted-living facility and hired a caregiver to take him to the doctor, the movies and the drugstore to buy Pepsi and cigarettes, according to the documents.
By 2007, Martin’s savings had run out. His family asked the government to step in.
No longer would someone visit Martin several times a week and drive him to the doctor. Instead, employees of the Maricopa County Public Fiduciary, whose caseloads are more than three times the national recommended average, would drop in once every couple of months.
They criticized Martin for missing medical appointments, according to reports to the court, even as they acknowledged his difficulty remembering things.
They kept him in care homes with little supervision, even as they noted his habit of disappearing.
“He often wanders off the property and goes to the local grocery store or convenience mart,” a 2015 report said. “(Martin) is independent, however he does talk to himself and can appear confused.”
In 2017, Martin was moved to South Mountain Care Center, “the least restrictive setting ... consistent with the ward’s needs, capabilities and financial ability,” in accordance with state law, Maricopa County spokesman Fields Moseley said.
“Not following the rules or being unwilling to comply with schedules makes it difficult to place some wards,” Moseley said. “(Martin) has been known to come and go as he pleases ... regardless of placement options.”
Martin left the care home sometime last June or July, Moseley said. He wasn’t seen again by county officials for nearly three months.
It’s not unusual for residents of South Mountain Care Center to leave for weeks or months at a time to panhandle on the street, the center manager told Bowie and a reporter when they visited. Residents come back when they want food, cigarettes or shelter, he said.
The facility had a wide-open gate. It is not licensed, according to the Arizona Department of Health Services.
A public fiduciary spokesman told The Republic the center is actually a “boarding home,” rather than an assisted-living facility that must be licensed, and that Martin is not required to live in a “medically licensed residence.”
Court records said the facility provides “three meals a day, laundry assistance, shopping assistance and medication prompting” and “a basic level of oversight.”
When Bowie visited the center, she was disturbed by the conditions, she said.
The buildings, where several dozen incapacitated adults live in small rooms, were poorly lit, with aging furniture. Cigarette butts were strewn across the ground. A fountain had no water. The kitchen had been cited in multiple health inspections, according to county records.
“It didn’t look like it could pass an inspection of any kind,” Bowie said.
Because the home doesn’t have medical staff, when the manager learned Bowie was a nurse, he asked her to examine a woman with a painfully swollen foot. She told him it likely was infected and needed a doctor’s attention.
County loses Martin
Martin was roaming the streets when he suffered his life-changing injury.
He was lying at a bus stop miles from home on Aug. 7, when two vehicles collided at 24th and Roosevelt streets, said Moseley, the public fiduciary spokesman.
One car spun out of control and pinned Martin’s right foot against the bench. He was taken to Maricopa Medical Center, where surgeons amputated his toes, Moseley said.
The county hospital transferred Martin to Camelback Post-Acute Care and Rehabilitation, where he stayed for a month, according to Moseley.
Maricopa Medical Center then filed a $110,541 medical lien against Martin for his amputation, records showed.
It appears neither medical facility alerted the public fiduciary when Martin was admitted, since Moseley confirmed his guardians were still looking for him during that time.
Maricopa Medical Center searches for surrogates, in accordance with the law, if medical staff members suspect a patient cannot make decisions, spokesman Michael Murphy said. He would not comment on Martin’s case because of his right to privacy.
The director of Camelback Post-Acute Care and Rehabilitation would not comment on Martin’s case but said the center follows safe-discharge protocols tailored to the patient’s needs.
The public fiduciary doesn’t know where Martin went after the Camelback rehabilitation center, Moseley said.
But a few days later, Martin arrived at Abrazo Central complaining of pain, Moseley said. The hospital gave Martin a prescription for antibiotics and put him back on the street, Bowie believes. Two weeks later, Bowie found Martin and brought him back to Abrazo Central. An infection required another amputation, this time to the knee.
On both visits, the hospital failed to notify the public fiduciary, according to Moseley’s timeline.
County officials learned of Martin’s whereabouts only after Bowie filed in court to become his guardian. Almost immediately, officials lost him again.
The public fiduciary called Abrazo Central after Bowie brought him in, but hospital employees said he wasn’t a patient, following the information ban placed in his file, Moseley said.
Martin’s “current whereabouts are unknown, and a missing person’s report has been filed” with police, the public fiduciary told Maricopa County Superior Court, even as the agency requested Bowie’s guardianship request be denied. The court complied.
It took county guardians three more weeks to figure out where Martin was.
Officials found him at Haven Health, a Phoenix nursing facility Abrazo Central sent him to.
After Martin’s ordeal, the public fiduciary plans to fit him with a prosthesis and place him in more restrictive housing, Moseley said.
County officials also want hospitals to do a better job notifying them.
Medical facilities should have searched for a legal guardian such as the public fiduciary if physicians believed Martin was unable to make or communicate treatment decisions, according to Arizona law.
If they weren’t able to find his legal guardian, officials were supposed to work with a spouse, relative or friend. Only after those efforts failed would a physician, in consultation with an ethics committee, have been allowed to make decisions for Martin.
But if medical facilities deemed Martin mentally healthy, state law wouldn’t have required the hospital to look for a guardian.
Jones, the Abrazo Central spokesman, said the hospital follows the rules.
The public fiduciary, however, believes “Abrazo acute hospital had a duty to the guardian to report that (Martin) entered the hospital and needed surgery,” Moseley said.
The county is “exploring ways to better educate medical facilities about their role and the easiest ways to determine if a person has a guardian that needs to be contacted,” he said.
Seeking solutions to ‘patient dumping’
Homeless advocates hope Martin’s case does more than shine a light on medical facilities dumping patients.
Resources for homeless shelters, mental illness, health care and affordable housing are all contributing factors.
“We’ve found there’s a temptation in the community to finger-pointing,” said Clark, the respite center CEO. “It really isn’t as simple as ‘Do hospitals dump, or do they not?’ ... Decades of inequities have led homeless people to where they are when they are hospitalized. Rarely is there one entity to blame for a bad outcome.”
Even if Circle the City expanded and hospitals stopped dumping, Arizona needs more permanent, supportive housing to make sure patients who have recovered can stay healthy and off the streets, he said.
“To aggressively scale medical respite care in our community without a parallel plan to scale permanent affordable housing would be a mistake,” Clark said. “We may end up simply kicking the can.”
Not long ago, Bowie visited Martin at the nursing facility. She brought him a newspaper and a puzzle book.
Martin didn’t remember the amputation or being rescued by Bowie. But they had a nice visit, she said. “He’s off the streets, in a safe environment, getting good care,” Bowie said. “That’s all I wanted.”
Now Bowie wants to help more people like Martin. Inspired by the experience, the longtime nurse has applied to work at Circle the City.
Circle the City and A New Leaf receive support from Season for Sharing, sponsored by The Arizona Republic. Donations can be made at sharing .azcentral.com or by texting “sharing” to 91-999.
Have you witnessed patient dumping? Are you a medical professional or homeless advocate with knowledge of this issue? Are you a decision-maker interested in reform? Contact consumer investigations reporter Rebekah L. Sanders at 602444-8096 or rsanders@azcentral.com.