"Injustice anywhere, is a threat to justice everywhere," Martin Luther King Jr.
As I'm sitting here, paperwork scattered all around me, digging through the past to turn this information over to the Department of Justice for their potential "real" investigation, including our old Diva, or CEO, Pam Ott, I cannot help but be bothered by certain things.
Oh, those things which don't add up, niggle at me, until I can hardly sleep.
Like these documents which clearly show that Pam Ott, the hospital board, the board's counsel, the CNO, the staff, all mandated reporters, knew about the problems, which included serious short staffing, and mismanagement.
A mandated reporter is anyone who knows or even just suspects there might be elder abuse. Similar to a good samaritan. You don't have to be a nurse or doctor, you could be a visitor, a maintenance person, a dietitian, a secretary, an accountant, but you have to notify someone if you think there is a problem.
My question to the state is if you took three why didn't you take everyone based on the elder abuse mandated reporting laws?
Or were the investigators fooled and easily manipulated like the rest of us into believing the leadership on the board and administration, human resources, were just "victims?"
And I'm wondering why the state's current case is so limited in its scope, and so out of touch with what really happened to cause the system failure in the KVHD skilled nursing facility?
It couldn't be simply the use of psychotropic drugs, as they are legal, prescribed and administered everyday in nursing homes across the country.
And when I say system failure that goes up the ladder doesn't it. You can't tell me there aren't pages full of penal codes that could've been used to punish the real problems at the top.
But it would take effort and money. It's a long story we have at KVHD, but once understood, it could be clarified in court.
It's not impossible. We know there are many laws supporting cases like this including the "whistle blower" act which I believe was enacted in response to the Enron scandal. What is peculiar to Enron is that the problem was at the top.
Enron wasn't the only paper shredding, employee bullying, justice obstructing organization, (KVHD) and hence laws were written to deal with that type of situation.
Employees of this hospital work for the biggest employer in the valley, and that should have been factored into this case, because it shows reasons for the actions and inactions of some of the staff.
Justice is just a word, the action behind that ideal is what counts. Calling what we have seen here at KVHD justice, would be like me calling Pam Ott's leadership, healthcare reform.
Elder abuse may have been a result of mismanagement, but it happened because the hospital let it happen. In fact they refused to stop the insanity and they were aided and abetted by big brother.
Let me tell you when the "sticky three" board members, (Brad Armstrong, Bob Jamison, and Barbara Casas) the CEO, CFO and others who knew the situation at the nursing facility, and for that matter, in the hospital in general, were let "off the hook" they thought they were impervious.
The DOJ, the Department of Health Services, the Kern County District Attorney's office, actually gave the criminal element at KVHD the confidence to freely short staff, allow an old system and old guard to remain in power, and then watch as leadership stepped down and ran out of town, untouched.
Yet the three people blamed, indicted, are gone, and the problems continued. Why? An inadequate investigation maybe?
Just three months ago, before a recent change in management, I walked in to the nursing center one day to find the staffing sheet not filled out and was told the SNF survey was not "ready" to be looked at by the public.
The hospital has spent almost three million dollars on the nursing facility consultants and temporary staff since the meltdown in 2007, yet the basics were not covered.
And in my opinion, there was no oversite of these administrators, no oversite of the money on the contracts, no oversight of personnel and policies, staffing, and a general attitude that if we close our eyes it will go away. As long as there were no reports from DHS, then it was considered good.
As a self reporting facility, the hospital adminstrator is required by law to report to the state any problems. I guess if you don't report it, then there are none. (Yeah.)
Complaints were recently revealed at our August board meeting regarding the use of "pink ladies" (not the drink) in the skilled nursing facility.
It was said that these volunteers spoke with Tracy Brown, the former nursing home administrator, and another former CEO, Rick Carter. They said they were not heard and nothing was done about their concerns.
It's a year later and finally these people spoke up. I think it is because they are beginning to believe things can change if you continue to do the right things, speak out, and not play small town, I'm a big fish, politics.
The DOJ has another chance to do something that they may not even know they can do, and that is to correct the situation, for all of us.
I know Mr. Fong's career is not going to be made here in the Kern River Valley, so I don't imagine he has too many sleepless nights over the dung trap of deception which occurred here. But his decisions regarding this case, will certainly make or break the careers of others. And they will either help or hinder this valley and its ability to get decent healthcare.
I need to know if the state Attorney General, Edmund G. Brown Jr., and investigator, Donny Fong, really want the truth or do they want to wrap this up and run off, forgetting all about us?
I'm concerned about the conspiracy charge against the Pharmacist, Debbi Hayes. I can't believe it's simply a coincidence that the upcoming preliminary hearing next week didn't have something to do with the new charge, and the new investigation of Pam Ott.
And again, conspiracy meaning more than one person, makes me wonder what the state is up to.
I truly want to send these documents to Mr. Fong, but I hesitate, wondering if they will not try to use this information in some other manner rather than in context to what has happened.
The state's case is really based on paperwork and Dr. Locatell an expert witness. The state's witnesses have already told me they will be hostile in court. Their own witnesses didn't believe in the investigation. That is a strong message.
But what is also of interest is that Pam Ott is a witness in the case. Which again makes me wonder about motivations here.
And the CNA (Certified Nurses Aide) I interviewed at least five times, told me the story of the day she showed up to work at the SNF in January of 2007. (The DOJ never interviewed her or so many others)
"All the nurses were crying, throwing away bottles of medicine in the trash. They were tearing down the care plans in the patients rooms, in the closets, which were outdated anyway...some people had died but the plans were never changed."
The state is basing a lot of information on paperwork. That should be "noted."
It's a quandry for me right now whether to send or not to send to the state. I'm wondering if these documents are better for the defense.
I'm questioning if the state's sudden interest in people other than the three they have charged, has to do with bolstering their own version of events, as errant as they are.
Really, its sad that I have to even question whether or not to send this to the state, whether I can trust the courts, the investigators, the attorney general.
But I am going to pray that there is integrity left in someone, and that this information will be used for that higher purpose. I really have no other choice except to trust.
Okay, Mr. Fong, if you haven't seen this document I'm sending then you never should have filed the charges that are existing against our doctor and pharmacist.
And if you have seen it, then we have even bigger problems than I thought. Let's hope for the best...
Persistance and Tenacity, requires a new chapter, a new beginning....
Well Laura I think you have good reason to doubt the ability or the willingness of our DOJ to get the right people for the crime. Because the managers never get in trouble unless someone like Pomir Or Hayes is the one to blow the whistle. It's not right, but that's the way it is. I don't care who tells who what. The bottom line is they did not have to do what they were told. They could have done the right thing and turned in the boss that was creating the problem. Instead they were complisit. Granted they were complisit with the guys that aren't in trouble (which of course doesn't make sense), but again that's the way it is. So yes send to the defense those papers, and be sure to explain as to a child, their significance to the prosecuters, when you send them their copy.
ReplyDeleteI agree that their is too much politics in the justice system. But what can we do about it?