UPDATED: Here's your original report Department of Health Services and state board of nursing: lot's of questions about the nursing center

Nursing Home administrator, Tracy Brown, giving her report to the board at the July, KVHD board meeting.

Brown and her company have been managing the nursing facility since 2008. But Brown came in with Sycamore Asset Mgt. in 2007.

Something has come to my attention with documentation to go along with it, so I have many questions and comments to go with it.

I'm going to show you a document signed by two nurses who came to work on the morning shift at the KVHD skilled nursing facility on 11/23/08. (however, the signatures are removed for privacy reasons)

The document indicates they checked the patients and found they were wet: one patient had a rash and another a wound. Alarms were not turned on, were amongst the items they reported.

The CNA's said they turned in this report to the nurses in charge. They both signed and dated it. The say the report never went to Department of Health Services in a timely manner which was deemed "unsubstantiated" in another document by the hospital.

But this report was not investigated, another KVHD document shows, until 2/13/09 and the date shown as the time frame investigated is the not the month shown on the employee document. The employee referred to in the following document is blamed for not telling administrators about the above report until February.

The CNA said the date and information was incorrect in this report.

She refused to sign the document and

filed a grievance with the hospital.

HR manager, Debra Hoffman cites the problem that the proper reporting form was not filled out. And the incident was not followed up by the CNA's

(Click on documents to open and read)

In another document,

dated 2/23/09, the HRmanager, now terminates the employee.

But the report shown here indicates that the allegation of suspected abuse has been "unsubstantiated." That means the hospital investigated and decided there was no neglect.

So, this report was investigated, the document says the RN and LVN who the CNA's insist they gave their report to, were no longer at the district or available for comment.

The HR investigation then indicates the very allegations were unsubstantiated, yet the nurse has been fired for not reporting it properly. It seems by these documents they wanted them to report but then deny their findings.

I need to know from DHS if they received this report signed by two aides in February when the HR manager, CEO, and NHA supposedly found out this information.

New information update: Earlier it was reported that the second CNA who kept her job, for an extra couple of months before she was fired, was asked to and did fill out the SOC reporting form regarding the 11/08 report on Feb. 13, 2009, the day the other CNA was suspended. She believes she filled it out at approximately 7 PM on 2/13/09. So, we are assuming DHS and the hospital have some record of this incident.

Now why would they want her to fill out this form if the hospital's investigation lead to the conclusion that the two nurse's aides claims of neglect, wet beds, skin problems, and a wound were in error.

If it was just a KVHD investigation and not reported to DHS for a look, then would the SNF administrator be responsible to turn in this report now? Or was it turned in recently? (see above)

That's an awful big reporting loophole as the hospital is given discretion to investigate themselves, leaving DHS out of the decision process.


Rick Carter in March 20, 2009 report denying the employee re-employment.Carter is quite harsh.


Now the unusual part of all of this, which needs to be answered and quickly, is that the first nurse is fired, then the second nurse signing the report regarding what they found on the morning of November 23, 2008 is fired for something different but after the first CNA.

Now one nurse's license is under investigation with the state board of nursing for not reporting what KVHD called an "unsubstantiated" allegation. This has happened months after the termination and nothing is mentioned by HR or the NHA that this will happen in their documentation.

The nurses license complaint happened June 24,2009, just over a week ago. The complaint emanates out of KVHD, unknown source, just the hospital. I've put in a request for information from the hospital as to why this is happening.

That is now nine months since the incident where patients were left in unacceptable conditions in the SNF and the report was made to the chain of command, according to the employees.

And now a complaint for "not reporting" is made against the CNA's license four months after the employee has been terminated.

The other CNA on the report has been fired and her license is being investigated for something completely different. She is concerned though that by signing the SOC form on 2/13/09 that she may be up for a second complaint by KVHD regarding the matter, even though they asked her to do it. She said she doesn't trust them.

Her story is that she was asked the very same day 2/13/09 the other employee was fired, to sign off on the DHS report, SOC form, for the incident that the hospital said in its reports never occurred.

One of the CNA's said she has been attending board meetings and maintains that she and the other nurse made the report to their superiors in a timely fashion. She says she will not stop fighting until the record is set straight and she gets her good name back. There were harsh remarks in these reports, but then there was a trivial write up for making a "smart" comment. (I guess I wouldn't last two minutes in the SNF)

Reports have surfaced in the skilled nursing facility of similar incidents, and some are claiming retributive actions. I will follow up.

Since questions have been coming in regarding the contract with the nursing home administrator, since I put it up on the blog, I will be requesting more documentation to answer people's questions. (hopefully information will no longer be blocked from the public)

Department of Health Services where's my paperwork?

I'll follow this post with a look at what we know now about the current administrator of the nursing center, Tracy Brown, and the controversy surrounding her arrival with the former contractor, Sycamore Asset Management.

Brown, who recently resigned her contract as the nursing home administrator, will continue to work until the end of August, as her contract has a 90 day clause.

In discussions with Brown, the SNF administrator said when asked about the $240,000 contract with the hospital, she said she turned down a $750,000 job to stay in the Kern Valley because she cares deeply about the residents.

Brown's contract pays for housing while she is in the area working.

The administrator who is contracted to work 40 or more hours a week, plus being on call for the facility, told me after she resigned she was asked by Board member, Brad Armstrong, and the Administrative assistant, Heidi Sage, why she resigned. Brown said she was surprised by the questions. Hmm.

What was Brad and Heidi's adventure into the SNF business about?

There will definitely be more on this story as there are too many lingering questions...



Another KVHD personnel policy
shows the Director of Nursing reporting
instances of actual or alleged abuse.





And then in the state
laws shown below are another
set of reporting instructions.




state laws