Pasadena nursing home evacuated after failing to provide basic medical services, city says

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By Bradley Bermont, Pasadena Star-News, June 12 2020

People come and go from the Golden Cross Health Care facility as it was evacuated because the operators were failing to provide even the most basic health services in Pasadena on Friday, June 12, 2020. (Photo by Keith Birmingham, Pasadena Star-News/ SCNG)

Patients at the Golden Cross Health Care nursing home in Pasadena were evacuated from the facility late Thursday night, after officials say the facility’s owners failed to heed the requests of local and state health officials, and failed to provide even the most basic care for some of their patients.

It’s the first time a nursing home in Los Angeles County has had its license suspended and residents removed during the coronavirus pandemic, a spokesperson for the California Department of Public Health told this newsgroup.

Representatives from Golden Cross did not return phone messages this newsgroup left.

The action was only due in part to the facility’s response to the coronavirus pandemic, city spokeswoman Lisa Derderian said in an interview Friday morning. The City Attorney’s Office is investigating the facility for violating local health orders, which leaves the door open for possible criminal prosecution.

Video from the scene showed dozens of ambulances lined up outside the facility at 1450 N. Fair Oaks Ave. about 11 p.m. Thursday and patients being placed inside the vehicles.

The Pasadena Fire Department was asked by the California Attorney General’s office to help move patients from the nursing home, Derderian said.

Officials from the California Department of Public Health later confirmed that the facility’s license was suspended “due to ongoing and serious quality of care concerns.”

Derderian said 63 patientsincluding many who have tested positive for the coronavirus, were evacuated and will be taken to various nursing homes around the region. None will require any hospitalization, she said.

The city “repeatedly and relentlessly” pushed the state to act, Derderian said, based on what Pasadena’s officials had seen on the ground and other reports delivered to local health officers.

Pasadena Public Health Director Dr. Ying-Ying Goh had recently conducted an onsite patient assessment alongside acting Fire Chief Bryan Frieders and were dismayed at what they had seen, Derderian said.

“The health care facility failed to do even just fundamental actions with the most basic care,” Derderian said, such as water and nutrition and basic medical services, such as offering  oxygen and diabetic treatments. She added the city had found 10 violations of state and/or federal law, which have been reported to state officials.

She did not outline the specific violations in detail, saying the matter was still under investigation, but did say one may be an infection control violation for failing to supply clean linens. Others may include violations pertaining to proper wound care, hydration and nourishment.

Nursing homes, assisted living facilities and prisons across Los Angeles County have borne the brunt of the pandemic, accounting for one-fifth of the county’s cases and about 42% of its deaths.

That includes figures from Pasadena, which operates its own health department. However, Pasadena officials say they’ve been able to thoroughly test all of the city’s nursing homes while Los Angeles County is still struggling to do so. Local officials have said the city has a more complete picture than the county, as result.

In Pasadena, nursing homes and assisted living facilities are home to at least 63% of the city’s coronavirus cases, though one-fifth of the city’s cases are still being investigated and could possibly be linked to the elder care businesses.

While Pasadena health officials have some legal authority over the nursing homes in their city, the facilities’ licenses are handled by the state, which contracts the work out to the Los Angeles County Health Department.

It’s been a sticking point for some Pasadena elected officials, such as Vice Mayor Tyron Hampton and Councilman Victor Gordo, who have been calling for local health officials to more closely monitor and take aggressive action against any violations from the elder care businesses.

Federal inspectors, as well as their county or state counterparts, made two visits to the facility in March and found it in compliance with COVID-19 requirements, according to data supplied by the California Department of Public Health.

On May 14, a complaint was filed against the facility for violating coronavirus-related health orders, but an investigation conducted by the state wasn’t able to find any deficiencies.

When a Pasadena Fire Department battalion chief visited Golden Cross on June 9, he asked the facility administrator if there were any “immediate jeopardy patients,” meaning residents whose immediate health and safety could be threatened by a facility’s failure to meet the state’s standards for care.

According to emails acquired by this newsgroup, the administrator told the firefighter there were no patients who fit that criteria. He followed up, asking if there any patients with unstable vitals, and she again said no.

When a nurse with the Pasadena Public Health Department visited the facility the next day, she learned there were “more than six” patients who were in immediate jeopardy “that were not shared” with the health department, according to an email sent to the state health department on June 10.

The nurse requested reports on the patients in question, writing it “would assist us to determine what measures we can act upon,” the email says.

The email was later forwarded to city leadership by Frieders, who said there were “nine patients in immediate jeopardy.”

Calling the state for help

According to an email sent to the Pasadena City Council and acquired by this newsgroup, City Manager Steve Mermell told local officials on Thursday, June 11, that the California Department of Public Health had served Golden Cross attorneys “with a temporary suspension order and accusation to revoke their license to operate.”

He continued: “Although Golden Cross has appeal rights, (the California Department of Public Health) has the authority to start depopulating the facility and moving its residents to other facilities, which should begin today (Thursday).”

Derderian said the Pasadena Public Health Department, City Attorney’s Office and City Manager’s Office had been involved for several weeks.

At the city’s prodding, a state team was brought in to run the facility about two weeks ago, Derderian said. The city helped house and feed the state workers, who would later transfer control of the facility to medical teams from the National Guard who were deployed to Golden Cross over the weekend.

In an email sent to the Pasadena City Council on June 9 and acquired by this newsgroup, Mermell told officials the facility’s management had failed to meet the minimum requirements to stay licensed.Sign up for The Localist, our daily email newsletter with handpicked stories relevant to where you live. Subscribe here.

Goh was onsite, Mermell said, helping to determine the best place to relocate these patients, “based on their clinical presentation and vital signs,” and whether they are coronavirus positive.

He continued: “I am advised, however, that the facility’s owner may be attempting to fight the relocation by pursuing a restraining order.”

Recently, the facility has been more impacted by the coronavirus than many other elder care businesses in Pasadena, an analysis of city data shows.

Even though new case counts had recently slowed at many of the city’s nursing homes, after officials completed multiple rounds of systematic testing, cases have continued to slowly tick upward for Golden Cross.

The city’s only coronavirus-associated death this month was linked to Golden Cross and reported to local health officials on Sunday, June 7.

Cases rapidly rose at the facility beginning in early May, around the same time officials began systematically testing all of the city’s nursing homes, city data shows. Then, the facility was still under the reporting threshold, indicating they had 10 or fewer cases.

By May 8, the facility was reporting 24 cases among residents, an undisclosed number of cases among employees and was linked to one death.

By June 12, the facility has reported 72 cases among residents, 32 among employees and has been linked to eight deaths.

On June 8, Mermell had sent an email to the council, saying “the owners of the facility are apparently putting up a fight with state licensing (the California Department of Public Health). … I fear this operator is precisely why additional state regulations are necessary when it comes to skilled nursing facilities.”

A history of violations

According to data supplied by the California Department of Public Health, Golden Cross has seen more than the statewide average number of deficiencies tallied by nursing home inspectors, but it received significantly fewer complaints than its peers.

In 2018, the facility was cited after an allegedly drunk worker threw a juice box at a mentally ill patient’s face. According to the state inspector’s report, the patient had thrown the juice box across the room. The worker left the room, came back with a new juice box, and threw it at the patient. The worker was employed by a contract agency and barred from returning to Golden Cross.

The facility has been cited for infection control violations three times between 2017 and 2019 for separate incidents. In one case, workers were found to have handled and disbursed antibiotic medications improperly. In another instance, a patient’s oxygen tube was left hanging on the ground in the middle of a state inspection.

During a routine inspection in 2019, inspectors found the facility had failed to asses and develop comprehensive care plans for 20% of the sampled residents. That led to mistakes, such as giving a patient the wrong amount of oxygen, or failing to record that one patient had lost 10 pounds in a month.

Basic building maintenance seems to be an ongoing issue for the facility as well; it was cited multiple times between 2017 and 2019 for having dysfunctional fire sprinklers and other structural violations.

In that same period, Golden Cross was cited once for failing to store food properly. Investigators noted butter had been left out on the counter while food was unlabeled and undated in the freezer; apples were stored in a milk crate. Containers of expired peanut butter were found in the pantry.

Staffing has also been an issue: The facility was cited twice between 2017 and 2018 for failing to have a surge plan in case of an emergency. Additionally, employees weren’t giving patients the attention required by law — 3.2 hours a day, the report says. It’s a figure that’s calculated by dividing the total number of nurses’ hours by the number of patients.

An undisclosed number of certified nurse assistants working for Golden Cross were found to have lapsed, suspended, expired or revoked certifications, it says.

“It’s a shame when the owners only look at it as a business,” Derderian said. “There’s no care or compassion for these residents.”

While this is the first nursing home in Los Angeles County to have its license suspended and its patients relocated, 83 patients were evacuated from a Riverside nursing home after employees failed to show up to work.

Local health officials are now calling on the state to review the that facility’s license.