Arizona board to review nursing home violation after Republic report
The state regulatory board that oversees nursing home administrators will consider investigating leadership at a Prescott facility that required employees to work while sick with COVID-19.
The decision to review the case came after The Arizona Republic in December reported on the nursing home’s safety violations, as part of a months-long investigation.
State health inspectors had discovered in July that managers at Granite Creek Health and Rehabilitation Center required staffers to work despite positive COVID-19 tests and doctors’ orders to isolate.
Some staffers were so ill that it was painful to breathe, or that they were “sweating and weak,” but had to stay on shift, inspectors found.
One employee texted the staffing coordinator, the administrator and the director of nursing about having a headache, body aches, sore throat and chills. No one responded. The next day, the employee logged a fever on the facility’s health screening. Still, management required working a full shift, according to the inspection report.
Over the next several days, that employee grew more ill and received a positive COVID-19 test.
At one point, the employee’s oxygen saturation level hit a dangerous 88 percent. The employee then went to the doctor, who said to immediately go to the emergency room. The staffing coordinator still required the employee to work, even given the doctor’s note.
The employee worked 12 hours that day in the ward for residents who do not have COVID-19.
The inspector’s notes say the employees they interviewed first developed COVID-19 symptoms in June.
According to data compiled by federal officials, Granite Creek, which is home to an average of just over 60 residents each week, reported its first confirmed resident case of COVID-19 the week ending June 21 — a week after it reported its first confirmed employee case.
Within the next month, 50 more residents got sick. Fifteen died.
The Arizona Department of Health Services fined the facility $500 for having sick employees care for residents.
A nursing home administrator did not respond to phone calls from The Republic requesting comment.
The inspectors found that the facility had put its residents in “immediate jeopardy,” which means the facility’s error put the health and safety of its residents at risk for serious injury, harm, impairment or death.
But Allen Imig, executive director of the board charged with licensing and disciplining nursing home administrators, said he was unaware of the case.
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After a Republic reporter asked why the board had not reviewed the finding, he said he would put the state inspectors’ findings on an agenda for the board to consider.
The board receives routine, automated records of some “deficiency” findings from the Arizona Department of Health Services. The Granite Creek report was never sent, he said.
“If it had, the board would have reviewed it,” Imig said.
The governor-appointed board, called the Arizona Board of Examiners of Nursing Care Institution Administrators and Assisted Living Facility Managers, meets monthly. Their next meeting is Feb. 8.
Statewide, more than 2,000 people have died of COVID-19 in nursing homes and other long-term care facilities, according to a Republic analysis, making those residents among the most vulnerable to the disease.
Arizona inspectors cited 64 nursing homes for infection control violations that could have spread the virus during the pandemic from March through October. Twenty-two homes had errors during multiple inspections, including Granite Creek.
Just a month before inspectors found that Granite Creek employees worked with COVID-19, they cited the facility because staff were not wearing PPE appropriately.
The administrators’ board reviewed that report. It is unclear why the board never saw the one about sick employees on the job.
Imig, the board director, said the board “wants to review” all immediate jeopardies that resulted in penalties or mandates.
Because Granite Creek was cited for an immediate jeopardy and fined, the violation appears to meet the board’s criteria. But Imig did not respond to follow-up questions seeking to clarify if the report should have been included in the state’s automated releases to the board.
Steve Elliott, spokesman for the Arizona Department of Health Services, said in an email that the citation did not match the parameters that the board seeks.
In July, before the state’s investigation was complete, Phoenix New Times reported about complaints of an outbreak at the facility. A Granite Creek administrator at the time told the paper that the facility might ask, but would not force, a sick employee to come to work.
The administrator said at the time that it was acceptable, based on CDC guidance, to put COVID-positive staff members to work with COVID-positive patients. But the state’s report later concluded that multiple staffers had told managers they were sick, but were assigned to work shifts in the non-COVID unit.
Shannon Parys of Tempe, a member of the nationwide group “Voices for Seniors,” which pushes for nursing home reforms, said the pattern of infections and deaths mars the entire industry.
“There is such a breakdown in this whole system and we need to get to the bottom of it, she said.
Parys, who lost her father to COVID-19, is suing the nursing home where he contracted the virus. She said taking legal action is her only recourse, since the state does little to hold accountable facilities that put residents in harm’s way.
“I feel like we were lied to,” she said. “Here we thought our loved ones were safe, because they were in lock down. Really it was the opposite. They weren’t safe at all.”