Administrator Frances Soriano: Case Study

The reporting party (RP) stated referral #1143-3655-1102-7078895 was generated from the following referral #0534-9062-5752-307279 dated 1/28/15 regarding resident Nicole Morris age 14 DOB: 6/1/00. Per the referral Nicole is an alleged victim of sexual abuse, physical abuse and general neglect by an unknown perpetrator. According to the RP on 1/28/15 a staff member named Rebecca took Nicole to Long Beach Memorial Hospital clinic to be examined after she disclosed having suicidal ideation. Nicole revealed to hospital staff that she planned to hang herself. While waiting at the hospital Nicole disclosed being "fingered" by two different boys (names unknown) at the home. Nicole also disclosed that a girl (name not provided) beat her up. Referral 0290-1132-4581-1002176 dated 3/13/15 reported by Tatiana Garcia, Clinician with Bayfront Youth Group home.

As noted, on February 29, 2016, the patient was nonetheless admitted to the UCR hospitalist. This was a senior member of the UCR hospitalist team who knew or should have known all of the policies and procedures for admission, and should never have admitted the patient as an attending to the hospital. In so doing, he was directly and deliberately interfering with the doctor patient relationship.

University Hospital is a well known hospital with a level 1 trauma treatment center for the tri-county area of a northwestern state, the hospital enjoys the fact they are known for their promising reputation among healthcare professionals and the public they serve. Jan Adams is an OR supervisor that has been working there for ten years, as a professional she makes surgeons follow protocol as required and enjoys working with trauma patients. One Friday night, which is the busiest day of the week for the trauma department; the unit was notified that a helicopter was on its way with a 42 year old man who had been in a car accident. Shortly after the patient arrived to the trauma center, the resident and other medical staff noted that he was in very bad physical conditions, needed immediate surgery or otherwise he was going to die. The issue was that the on call surgeon had to be present during the surgery and had not yet arrived, but regardless of the matter and protocol they proceeded with medically treating the patient immediately. The concern is that in doing so they violated medical procedures and put the patients safety at risk, this lead to a long list of ethical issues for example, patient well-being, impaired healthcare professional, adherence to professional codes of ethical conduct, adherence to the organization’s mission statement, ethical standards, and values statements, management’s role and responsibility, failure

OFC Montejano made contact with the Hegle at Primary Care Desk B lobby. Where the she gave an omission and stated she had an appointment and because the Johnson was not at her desk she missed it. Further, she claims Dr. Little told her she could get the Tens Unit right away. I did however confirm that Hegle did not have and appointment for the use of the Tens Unit. Hegle was given a verbal warning that this type of behavior will not be tolerated and she could be charged with Disorderly Conduct in the future. Hegle departed VA Controlled property without further

According to former employee Stephone Else, medication aide, alleges she heard Ms. Lyles tell Phillip Yovonnie, LVN to “Take her to China” with Amara Anele, RN, and Lilian Foster, Medication aide present at 6:20-6:30am. Per the investigation, the date was identified as 1/23/18 and resident was Shirley Depino. According to the nurse Amara, she did not give any medications

Trey Cavalier was assigned to M&N control for the night. That morning (which was May 14, 2016 because he was working nights) about 30 minutes to an hour (he could not give exact times because log books were being picked up for the investigation) before 4:00 a.m. Dy. Cavalier was notified by Dy. W. Benson that Brian Ducre (who was a new move that was escorted to M&N on a wheel chair) was acting strange and that medical needed to see him. Dy. Cavalier called the medical department and spoke with Nurse Minor and advised him of the situation. Shortly after Nurse Minor came off of N01 and said that inmate Ducre had mental problems and wasn’t taking his medicine, that there was nothing the Nurse could do for Ducre and that he would ultimately be okay. Nurse Minor then left

Two experienced nurses had been working at the Winkler county hospital for more than 20 years. In 2009, Ann Mitchell and Vicki Galle became whistleblower in the small town of west Texas. The nurses field an anonymous report to Texas Medical Board regarding to retaliation in the hospital. In the letter, the nurse stated the unsafe practices of Dr. Rolando Arafiles. The nurses were concern about the improper treatment to patient provided by Dr. Arafiles. Since. Dr. Arafiles tried to misuse his connections in order to save himself. Upon receiving the notice from the Texas Medical Board, Dr. Arafiles contacted his good friend and patient-Winkler county sheriff. Dr. Arafiles filed a complaint of harassment by the nurses to the sheriff. The sheriff started investigating the complaint and obtained the copy of the TMB report that clearly identifies that Mitchell and Galle had filed a complaint. Then, the sheriff obtained a search of warrant and seized each nurse’s work computer and found the copy of TMB letter. The nurses were charged with the third degree felony for misuse of official information to cause damage to the physician. However, the TMB disputed with District and County Attorney over the charges asserting that there was no misuse of official information in the state-governing agency. The complaint process allows anyone to report a physician for any unsafe, improper or poor practice including nurses. Since TMB is a government agency there was no violation of Health

Reporting party resident Michale Dean Lopez (DOB: 11/3/58) stated that approximately 2 months ago, that he was lying down in his bed and felt something behind him. Resident stated that he jumped up and turned around and resident Chris (last name unknown) was standing at his bed side with his boxers down and his "thing" sticking out. Resident noticed that his boxer were down half way. Resident does not know for sure if Chris penetrated him but stated that he felt funny and that he takes Ambien along with Trazodone. Resident reported this incident to staff Zack who told staff Nancy. Resident wanted to contact law enforcement but Nancy told resident not to worry and that everything would be okay and to speak with Mr. Beasley. RP stated that he

On this date, APS supervisor talked with worker at Amedisys HH in Mobile Co. Amedisys called to report Mr. Parker was left alone in his caregivers apartment since Saturday and she does not plan to return for two weeks. According to Amedisys Mr. Parker is receiving speech therapy, physical therapy, and nursing services. The apartment is two levels and his bedroom is upstairs. Yesterday they believe he took the wrong medication and overmedicated himself and the home was smoky where he tried to cook food. He is also isolated in a dangerous area with no phone service. According to HH, they have called Ms. Nash, the caregiver, three times and she has not returned any calls. APS supervisor referred Amedisys to Mobile Co.

On 5/13/2015 I met with Dr. Navato at Centerpoint Medical Center. Dr. Navato was familiar with the complaint as she had submitted a narrative response to the BHA in February of 2015. The allegation was that Dr. Navato did not honor a (Do Not Resuscitate) order.

The reporting party (RP) stated there is a resident named Dale who is very difficult to engage. The RP stated Dale has "called him out" to fight. The RP stated he felt threatened by the resident and called the police. According to the RP the police told the administrator/owner Beverly Juniel to give the RP an eviction notice. The RP stated Dale steals personal property from residents and has defecated in the yard. According to the RP Dale does not want to be in the facility but does not control his money. The RP stated Dale's sister control his money and refuses to move him. Because Dale's sister does not buy him cigarettes he steals them from residents including the RP. The RP stated he walked away from his cigarettes and lighter for a few

On 5/8/16 Client Antionette Williams #239 got into a fight with a resident on Unit #206 Shaundenis Pagan mother, the client stated that Ms. Pagan started by know oh her door asking for cigarettes and then proceed to another resident unit and told that person that Ms. Williams was talking about her, that situation escalated leading into an argument between, Ms. Williams, Ms. Pagan and Ms. Chanel Grant. After the argument on the second floor, Ms Williams decides to go to the parking lot for a fresh air, while Ms. Pagan went into her room and put her sneakers provoking other the other residents, they all went outside the building at the same time, Ms. Pagan mother arrives to drop her granddaughter with Ms. Pagan, went they all starting to fight.

On 25-Aug-15, at approximately 1545 hours, the writer and Acting SSL C.Tessarolo responded to a call from POC to attend PHAU, because one of the patients has ran out of the unit. The writer was on his way to PHAU, while he noticed two clinical staffs being physically engaged with the patient by the LAB. The writer rushed to the location and asked the clinical staff if they wanted the officers to take over and escort him back to the unit. The clinical staff had a strong hold of the patient's arms, so they told the officers that they will be fine, but they asked the officers to accompany them, while they are taking him back. The writer and Acting SSL C.Tessarolo along with the clinical staffs escorted the patient back to the unit and secured

The reporting party (RP) stated she is the conservator for her nephew Michael McKinnon is not allowed to make or receive phone calls. According to the RP the facility staff members are to assist Michael to make a telephone call to his family every Sunday. The RP stated the facility staff refuse to assist Michael to use the phone. The RP stated the phone is located in the kitchen which is off limits to the residents. The RP stated she received a text from the facility stating that Michael is receiving a 30 day notice. The RP stated the facility is retaliating against Michael due to persistent involvement in his care. According to the RP the facility is doctoring and falsifying Michael's records in an attempt to justify the eviction. The RP stated

On Friday, June 10, 2016 at about 2332 hours, FHEO Security was dispatched for a (51D) Disorderly Patient at the Special Care Unit (SCU) room #37. All Security staff responded to the call and met with RN Francesca Plaza who stated that the patient, James Patrick Hogg (FIN: #85758458) was agitated and would not listen to medical staff. Mr. Hogg had come in by EMS with Altered Mental Status (AMS) and was uncooperative with medical staff. Nurse Francesca Plaza had requested Security staff to stand by while the patient get medicated. Security Officers Omar Alonso, Michael Chin along with Supervisor Steven Evans went in the patient’s room while Patient Tech Alex Almanza and Nurse Plaza administered the medication by injection without incident. No