Citing Two Pasadena Cases, State’s Inspector General Raises Concerns About Ability to Handle Nursing Home Crises, Complaints

An interim report issued by the Office of Inspector General Monday questioned whether the Los Angeles County agency responsible for oversight of skilled nursing facilities can effectively address crises and protect residents’ health.

The assessment of the county’s Health Facilities Inspection Division centered on two emergency evacuations from Pasadena facilities in June and October 2020.

Those events “highlight flaws in HFID’s crisis identification and response and resident abuse and neglect investigations,” the report found.

OIG investigators spoke to more than 40 staff and supervisors in the division, many of whom said they feel pressure to close investigations of complaints quickly, and sometimes prematurely, given a backlog of more than 5,000 cases.

“Numerous staff communicated the belief that HFID leadership appears to prioritize closing investigations, at times, over the wellbeing and safety of SNF residents,” according to the report.

The report also included a final analysis by the county’s auditor- controller identifying “significant operational deficiencies that appear to impede HFID’s ability to fulfill several of its oversight responsibilities”

Auditors found that HFID employees spent less time on oversight when compared with state investigators, despite similar training and expertise.

Even when complaints are thoroughly investigated and substantiated, it can be difficult to ensure the safety of residents if that requires moving them out of the facility, as evidenced by the two incidents in Pasadena.

The complicated interaction between the state public health agency that controls licensing and enforcement and the local public health team responsible for oversight has led to a situation where it is unclear when to declare residents in jeopardy and begin a crisis response, according to the OIG’s analysis.

Research supports keeping elderly, frail residents in place whenever possible, making such a decision fraught to begin with. Any number of local, state and federal agencies were made aware of problems at the Golden Cross Health Care facility in Pasadena and spent weeks trying to remedy potentially life-threatening issues before moving to evacuate more than 60 residents on June 11 — after the facility’s state license was suspended.

“By the time the decision was made to evacuate the facility, 71 residents and 32 staff had contracted COVID-19 and 16 residents had died,” the OIG reported.

“Officials from the PPHD [Pasadena Public Health Dept.], the Pasadena Fire Department, Ombuds and the CAL-MAT (rapid deployment team) expressed the belief that Golden Cross should have been evacuated sooner.”

One of the most critical breaches of protocol by the facility, flagged in May by a state nurse, was that Golden Cross wasn’t keeping residents with positive cases in an isolated area away from other residents.

Problems in complying with COVID-19-related health orders were exacerbated by staffing shortages created by an outbreak of the virus that led to the facility employing many temporary workers as nurses. At one time, the U.S. Navy was called in to help supplement staffing.

Nearly a month before the evacuation, the county Health Facilities Inspection Division declared that multiple conditions posed “immediate jeopardy” to residents and called in a state rapid deployment team to help remediate problems.

However, the HFID opted not to evacuate immediately, but to place Golden Cross on a 23-day “termination track.”

The state team subsequently raised additional concerns, pointing to the staff’s failure to medicate residents in accordance with doctors’ orders and noting that several residents had lost weight due to a lack of adequate food and water.

As the problems and complaints piled up on May 27, the Pasadena Fire Department came up with a plan for evacuation and a nonprofit social services organization identified an alternative facility within 15 miles. HFID leadership said they were waiting on guidance from state officials.

In addition to issues related to coordinating with the state, HFID is not well integrated in the county’s public health department, according to the report. DPH leadership wasn’t informed of the issues at Golden Cross until a few days prior to the evacuation, the OIG reported.

The findings were released after business hours, and DPH could not immediately be reached for comment.

Less than four months after the Golden Cross evacuation, on Oct. 1, more than 30 residents were moved out of Foothill Heights Care Center due to excessive temperatures in the facility. In this case, as well as the one at Golden Cross, HFID was seen by some as slow to react to a crisis.

The first complaint about excessive heat was received by HFID on Aug. 19, and staffers conducting on-site inspections found temperatures ranging from 91.5 to 94.5 degrees.

The agency issued an immediate jeopardy finding on a follow-up inspection the following day and returned to monitor the temperature for several days thereafter until concerns were abated.

When a heatwave struck in October, officials from Pasadena and HFID arrived unannounced at the facility and found temperatures of 92 degrees, despite hourly logs stating that no room was over 82 degrees.

Within four hours, all residents were evacuated after the fire chief reached out to state officials.

In addition to the concerns about reacting to crisis situations, the OIG and related audit also identified a backlog of thousands of complaints awaiting investigation.

As of June 30, 5,407 investigations remained open, nearly half of which have been open for more than three years. A total of 547 were categorized as posing immediate jeopardy.

“The failure to investigate complaints in a timely manner can limit HFID’s ability to … substantiate allegations and prolong situations in which residents may be subjected to unsafe circumstances and neglect,” the report concluded.

The OIG offered 13 recommendations, including designating a crisis mitigation team with clear protocols to trigger an emergency response and a plan to better integrate HFID staff into the public health department.

It also called on DPH leadership to assess the accuracy of concerns raised by HFID staffers about a lack of training and undue pressure to close inspections.

“If true, the issues alleged may impact the county’s ability to oversee SNFs, protect the health and safety of residents and fulfill its contractual obligations with (the California Department of Public Health,” the report stated.

“If reported accounts are untrue, the common perception of multiple HFID staff and supervisors is itself concerning and calls for further evaluation and appropriate intervention.”