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  • Writer's pictureAaron J. Byzak

Sexual Assault Allegations Stir Memories of Negligence at SNF

This morning while reading the San Diego Union Tribune, I came across an article in the Local Section titled "Nursing Home Sued in Sex Assault." Written by Pauline Repard, this piece details a $50 million lawsuit stemming from allegations against a skilled nursing facility in Hillcrest where an 88-year-old woman was sexually assaulted in October.

As many of you know, Hazel's Army was born out of the tragic death of Hazel Mensching--my grandmother--in 2013 as the result of negligence and neglect at an assisted living facility. In the wake of her death, we created Hazel's Army to bring meaningful legislative change to protect this vulnerable population. But her death was simply the straw that broke the camel's back.

My interest in protecting seniors in assisted living and skilled nursing facilities dates back many years to my time working in Emergency Medical Services (EMS), including countless calls to these facilities for patients who obviously had not received proper care. One call in particular stands out in my mind--and it happened at the same skilled nursing facility in Hillcrest where the woman was recently assaulted.

Early in my career in EMS I was assigned to a basic life support (BLS) unit that held cover primarily in Hillcrest to transport bed-bound patients between facilities, hospitals and skilled nursing, for instance, as well as to take patients to physician appointments and treatments (such as radiation therapy).

One of those patients was a woman with diabetes who resided at that facility. Let's call her Dolores. Dolores was a wheelchair bound woman with diabetes who required transport to appointments several times a week. Over the course of about six months we got to know Dolores very well, so much so that I knew her social security number by heart. We also watched her endure amputations as the result of her diabetes.

The call in question came to us as a code response (lights and sirens) for a patient with altered level of consciousness. It was the middle of the day. When we arrived on scene, we proceeded to the second floor and walked into the patient's room. It was Dolores. My partner was patient person, so he started assessing her while I went to gather more information about the events leading up to this emergency.

I walked to the nurses station and there was no one to be found. Not a single staff member. I walked down the hall calling for someone. Finally a single nurse hurried by me.

"Can you tell me anything about this patient?" I asked.

"Not my patient. Shift change." she yelled back. Yep, I'd heard that many times before.

With that, I went behind the nurses station and pulled our patient's chart, the binder containing a play-by-play accounting of her care. I flipped it open to the most recent pages and quickly realized what had occurred.

On my off shift, three days prior, Dolores had suffered a stroke. She was unable to talk or swallow. She had been treated at the hospital and then returned to the skilled nursing facility. Typically, someone in that condition would have a gastric tube or G-tube placed to provide nourishment. Dolores did not have a G-tube so she hadn't received any nourishment in several days, but the nursing facility had continued to give her insulin. This is a major problem.

"No food for three days, but still getting insulin," I yelled to my partner.  That pretty much describes why she is unconscious--she's extremely hypoglycemic.

I walked back in to the room where my partner was taking vitals.  

"The hospital is three minutes away, let's get going."  

As I started packaging my patient (getting her ready to go), I glanced over to her roommate--the patient in the other bed. She was dead.

"Dude, I think this lady is dead," I said to my partner.

I walked over to her.

"Ma'am! Ma'am! Wake up!" Nothing.

Sternal rub. Nothing.

Grabbed her jaw. Stiff. Rigor Mortis had set in. She had been dead for some time.

I yelled out the door, "Hey, you guys!  You guys know this patient is dead, right?!"

The nurse came in to the room. 

"Oh yeah...I guess she is." Blank stare. Turns out they had documented that this dead patient had a blood pressure of 120/80 only ten minutes before I found her. Right. The person in full rigor mortis had a perfect (i.e. never seen in anything other than a textbook) blood pressure just a few minutes prior.  

It was clear that staff members were faking vital signs in their charts. 

We quickly transported Dolores to the hospital, where she passed away a short time later. Two patients dead in one room. 

We reported the conditions at the facility to the appropriate authorities.

Fast forward 20 years and it seems that very little has changed.

According to this morning's San Diego Union Tribune story:

The records say eight complaints were filed against the nursing home in 2019, with 14 findings of “deficiencies” involving pain medications, diet and accommodation for a disability. The government levied a $2,000 fine in one case.

In 2018, the records show, 10 complaints were filed with seven findings of deficiency. In 2017, 18 complaints were filed with 19 deficiencies found.

The California Legislature tackled assisted living reform in a big way in 2014. Perhaps the time has come for skilled nursing to receive similar attention.

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