Okay, Donny Fong, Jerry Brown, I'm sending you the information, but with some hesitation

"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...

The disaster, the crimes, when does it end?

Bradley Armstrong, current Treasurer of the Kern Valley Healthcare District, sits in front of his computer deflecting all scrutiny of his activities within the district for more than 20 years. Brown Act violations, conflict of interest issues, bullying, and ignoring serious problems highlight his stay on the board of directors.

They worked together hiding their activities from the public, the employees, and other board members, and created the biggest disaster in the history of the Kern Valley healthcare district when idictments came down from the state Attorney General's office for elder abuse earlier this year.

The charges, stemming from an investigation during the time period between August 2006 and January 2007, were only against a long time doctor and pharmacist, and a director of nursing, who was hired and left during the same time frame. Others got away with their part in the downfall of the skilled nursing facility; and some are still here...

Bob Jamison, 2nd vice chair, still with the board of directors, spent much of his time at his radio job with QAB media protecting the truth about mismanagement and the rest of the time attacking employees along with anyone who questioned the former CEO, Pam Ott. Jamison was one of three board members, a quorum, who ran the hospital into the ground.

Jamison blogged on the QAB media, an ABC affiliate station, website creating a media war as the three board members and administrators were being scrutinized while investigators were roaming the nursing facility at the hospital. When CEO, Pam Ott, stepped down, May 2007, during the impending disaster, Jamison further aggravated the situation, by bringing Ott on the radio and allowing her an hour to defend and blame others for the problems.

The board of directors was lopsided, as Bradley Armstrong, Bob Jamison, and former member, Barabra Casas defied all laws surroung legislative bodies, the Brown Act, putting votes aside when one of the members was absent, thus losing their private quorum. They even went to the extent of canceling a meeting in April 2007 when the questions started coming about what the problems were with the hospital nursing facility.

Email from Barbara Casas RE: April 2007 meeting: Bob Jamison was elected to the office of First Vice President, which was his desire, so he could Chair Board Meetings if Brad had to be absent. Bob Jamison chose to not have the Board Meeting on Thursday as he was afraid that everything would be a 2 to 2 vote without a third positive vote from Brad who is Chair, and the third person to vote for anything positive.

....….Know this—If I was acting as First VP or Chair, I would have carried out meeting on schedule, I would have only tabled the action mentioned before the meeting—that could have been accomplished by a telephone vote of all Board Members—I would have chosen to go ahead and let them make fools of themselves, but then, that is me, and I “charge ahead”-----that is what I would have done!

Pamela Ott, former KVHD CEO, from 2003 until her resignation in 2007. Ott shown here at the South Fork Woman's Club attempting to get the organization to back a general obligation bond for 12.5 million to build a new wing on hospital. The bond was lost, but the building plans were never feasible anyway.

The former CEO spent most of 2006 dealing with the Department of Health Services as the Skilled Nursing facility was fined for noncompliance regarding physical restraints of residents. DHS requested that there be a full time Director of Nursing in the SNF, and though Ott, and then CNO, Sharon Brucker, stated compliance when they brought on a DON in March 2006, she lasted only a few weeks.

2006 documents

regarding the use of physical restraints. Ott, an RN, had little knowledge of long term care laws.

But as the district was trying to push its general obligation bond, Measure M, onto the November 2006 ballot, a new employee arrived who took over the skilled nursing facility as the director of nursing, Gwen Hughes.

Ott glowed about the acquisition of such a qualified manager, and reported in her September 2006 CEO board report that things were going well. At the time employees had already begun to make rumblings that trouble was in the SNF and the hospital. But Ott insisted things were "wonderful."

"Nursing Center Update: Things are going very well in the nursing center. We admitted six new residents in one week. The total census is 72. Our new director of Nursing, Gwen Hughes, is organizing, making appropriate changes, adjusting to her role and the staff really seem to be enjoying her leadership."

Then in Oct. 2006, employees came to a board meeting to let the directors and management that there were serious problems with staffing. Chairman, Bradley Armstrong instructed the speaker to go up the proper chain of command. Rather than see the situation as an alert that problems were afoot, Armstrong, reprimanded the employees.

Suddenly, in November 2006, a month later, the problem was investigated and resolved. All assertions made by the employees, the report says were not substantiated. A committee was formed to appease the group.

both of the employees who were in charge of the recruitment and retention committee are no longer employed with the hospital. One nurse was called "one of the best" by doctors and fellow staff.

By April 2007, then board Chairman, Bradley Armstrong, began refusing to answer questions regarding the skilled nursing facility or any short staffing suggestions.

That was the month he had to have the board meeting cancelled because he couldn't attend, suddenly. The meeting went April 16.

Brad Armstrong backed Pam Ott, as no questions were asked of her in a public forum, questions were deflected, and no accountability was offered.

Armstrong also strongly backed the architectural firm, Aspen Street Architects, the company owned by David Yarborough, as the hospital was working with Rural Health Design Network, owned by wife, Kathy Yarborough.

The plans produced for the concept modular building tied to Measure M, were faulty, yet because the district had a long relationship Aspen Street, already paying much money over the course of several years.

When the project went up for bid in March of 2007, (by law, projects costing more than 25K have to go up for bid) Armstrong, Jamison and Casas all voted for Aspen Street.

The other two board members, Robert and Kathryn Knight, picked another company after doing research and finding out about the cost overruns Aspen Street had been having on their other projects.

Barbara Casas said she wanted to go with Aspen Street after working with them for five years. Even after the renderings were made for the previous GOB, and they were faulty at a partial cost of $5000.

Chairman Armstrong only researched two of the three firms, and went with Aspen Street in spite of their previous errors. Partial records indicate Aspen Street Architects was paid more than $30K. Not clear what services were provided which were correct and finished.

The hospital has dropped it's contract with Aspen Street and denied for months knowledge the relationship between the architects and the other organization, Rural Health Design network.

Chet Beedle, Chief Financial Officer, contracted with two different management companies for the ailing nursing center. After minimum or short staffing, Beedle spent more than a million dollars to rehabilitate the SNF.

The board of directors signed off on the strategy which has cost the district dearly.

Chet Beedle, who pushed for Measure M, going on TV with Bob Jamison, selling the bonds without any true construction plan or detailed figure.

Beedle, who came to the district through a management company called BRIM, in 2001 as the controller, was then hired on as CFO.

The CFO worked closely with Armstrong, Jamison, Casas and Ott as they closed in on the bond meant to pay for a structure that was amorphous at that time, and still is not settled.

With the Knights disagreeing with the process, the group went about telling stories about the Knights which ranged from being thieves to walking the halls at night talking to employees.

Beedle targeted an employee he called a "Knight supporter" who said he didn't trust management and was not behind the bond which would have the community paying for the project with property taxes.

Email following a meeting in December 2006 regarding the Knights and an employee:

What I said was that Tom received double digit salary rate increases while most of the other employees' salaries were frozen. All of these salary increases were granted by Bob Knight. The actual history is al follows:
1) 9/28/97 - Annual increase of x%.
2) 12/1/97 - Special salary adjustment based upon survey of comparable positions - Increase of xxxx%.
3) 7/1/98 - Special salary adjustment for increased responsibility for Durable Medical Equipment - Increase of xx%.
4) 9/27/98 - Annual increase of xx%.
I am sending copies of the Personnel Action Forms signed by Bob Knight for these increases to Pam as per her request. I think this tells the story.

(Figures have been removed for privacy purposes.)

Mr. Beedle has firmly said that there are no billing problems at the hospital. And even after the end of the contract with EMCARE in 2006, the company he blamed for the overcharges, there were still complaints coming in.

One public comment stated that when he was dealing with the billing department he felt they were not up to speed on what everything was and that they always turn and talk to someone above them.

Other residents have claimed they still get bills over and above their own insurance, though Beedle denies having any complaints.

Currently, the board of directors consists of Kathryn Knight, chairwoman, Secretary, Victoria Alwin, 1st vice chair, Dr. Robert Gross, Bradley Armstrong, Treasurer, and Bob Jamison, 2nd vice chair.

A new CEO, Tim McGlew, has recently joined the district and will be attending his first board meeting this week, July 1, at 5:30 pm in the hospital cafeteria.

Even with evidence that there were leadership problems, board members voting together and violating laws to make sure they had the vote, personnel records revealed, slanderous statements about board members and employees, there has been little recourse or action by any oversight agency.

Currently, Armstrong and Jamison have been subversive in their activities trying to blame other board members for mistakes, yet neither of them has yet to even take responsibility for their own actions. But two people who have served the district are now in criminal court, Dr. Pormir and Debbi Hayes. And the hospital insurance company has denied that they have to pay for their defense.

Armstrong seems to not be able to let go of his former power to control the board and administration, and has berated and harassed the new chairwoman as she took over just this January. Upon taking over the middle chair, Kay Knight, had a sudden surge of visits at her workplace by Beedle, former CEO Rick Carter, and a reportedly pushy Armstrong.

The incidents were reported to the board counsel, Scott Nave. He has also recieved evidence to the facts and has chosen not to act.

Reporting on a special meeting, I was kept from getting the report from the legal counsel via telephone as Armstrong reached in front of me and hung up the phone.

Records have been denied and kept from me over the past two years. Which again is illegal. It hasn't ended.

Click on images to open and read.