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

Updated/Corrected: SNF employees fighting back: "They knew about it."

More information/New documents:

Two employees say they wrote up this report of the conditions found on the morning of November, 23, 2008 in Hall 3 of the KVHD skilled nursing facility and turned the handwritten and signed document to the nurses in charge.

They say they turned the document into two traveling nurses who quit the hospital a month after the incident.

And they say that both nurses, LVN Sonjay, and RN, Reno, told them that they had submitted the report to the DON and Tracy Brown, the Nursing Home Administrator, whose company, Quality Healthcare, took over after Sycamore Asset Management in 2008.

The employees say that they trust the two nurses did what they said they did. "Sonjay and Reno were the best thing that happened to that unit, but they couldn't handle it working there."

The employees were told they didn't have to do anything more by Reno, it was all taken care of was their understanding they said. The said they asked and were reassured at least three times.

But when they saw that the aide the above report refers to, come to work after the incident, they became suspicious and scared.

"When she was back on the floor, we were petrified we were going to be fired," she said. "If we had done what she had done we would've been escorted off the property."

They said they took their concerns again back to Reno, who told them the report was made and they could go back to work.

"We were told just go back to work." She said Reno told her he couldn't tell her anything about the nurse because it was private employee information.
(At this hospital? Right Chet?)

The two traveling nurses quit and moved somewhere in California.

Then in Feb. 2009, one aide said she found herself in a quandary as to what to do after she asked Tracy Brown and Human Resources manager, Debra Hoffman, about the status of the report.

The two administrators told her they had never heard about it and blamed the aide for not telling them, the aide claims. She was suspended for not reporting and making a "smart" comment, and they said in the HR report shown below, the hospital, would investigate.

In the second HR report, they said they investigated, but were unable to reach the nurses who the aides say they submitted their report to, Reno and Sonjay. (documents below)

One of the aides was able to find Sonjay and spoke to her after she was suspended regarding the issue of the report. She said Sonjay told her that it had been reported to the administrator and DON.

The first aide was fired for not reporting the incident to the administrator and not on a correct filing form. But the in house investigation conducted (?) lead the administrators to call the aide's report of neglect, "unsubstantiated."

So, the aide was terminated for not properly filing a report about an incident which they said they could not substantiate or prove. And the documents state they could not reach the nurses who the aides say took the report. (Not much of an investigation)

The employee said she saw the dates were off on the form HR put in front of her to sign during her termination ceremony. And the information, she said, was also not correct. She refused to sign. Which is indicated on the document shown below.

On the same day the first mandated reporter was suspended, Feb. 13, 2009, the second aide said she was called in and asked to fill out the state reporting form at 7 pm. She filled it out, she said, because she thought if she didn't she would lose her job.

It's not completely clear right now when and if the report was ever filed with the Department of Health Services. Or if the SNF and HR still claim it was not a substantiated incident.

And that is one of the big problems with self reporting facilities. Especially, after all the investigations at KVHD, wouldn't it look better if it was just handled in house? Department of Health Services or the Ombudsman don't have to know. (Right Pam, that's how it's done?)

The ultimate responsibility to assure the initial report goes to the proper authorities falls to the administrator.

What makes this claim so interesting is the hospital's documentation doesn't make sense and looks highly suspicious.

Both of the mandated reporters have been terminated, but now, suddenly, after four months, a complaint against the first aide's nursing license was filed with the nursing board, on June 24, regarding not reporting the incident or non incident whichever. It seems HR, Rick Carter, and Tracy Brown have used both scenarios to justify their actions according to the documents.

The letter from the state nursing board the aide received states the complaint comes from "KVHD." (Trying to find out where this was generated from after the employee has been gone four months.)

The first aide fired on Feb. 23 of this year after going up the truncated chain of command to former, CEO, Rick Carter. Though there is confusion about the chain between the employee handbook, the recent explanation by KVHD board counsel, Scott Nave, who said it falls back to the personnel policy.
(termination greivance policy. Click to open)

Both employees just want their jobs back, their names cleared, and any false complaints dropped. And they also want to make sure the new administration hears about what they say, "has been going on."

The aides say they have spoken with an attorney and the EEOC, and they said both found the district claims unbelievable or even irrational.

But the aides want to stick with the district, but not in the nursing center, because they believe they are being retaliated against because they made a negative report which they think was being buried by the SNF administrators.

Tracy Brown, Nursing Home Administrator, for the SNF at the July board meeting. Though Brown has resigned, controversy begins to swirl around, as employees are fighting back after terminations. But the administrator has been controversial as her management company contracted for $240K and traveling nurses costs skyrocketed. More to come...

Click on documents to open and read.