Dignity Health Care Case Study

The reporting party (RP) stated resident Arev Dabbagh DOB: 12/27/00 disclosed on 4/15/16 she inappropriately touched by a male peer. According to the Arev on 4/14/16 a peer Ibraheem Mamoori DOB: 9/2/98) placed his hand on her shoulder and continued downwards towards her breast. The peer touched her breast over he clothing. The resident was distraught while she recounted the incident. Arev alluded to their being other incidents with the peer and other unknown males. Arev didn't disclose details or clarification. Arev was placed voluntarily in the facility by her mother and will continue her placement for a few more weeks. The peer is currently placed on a 5150 hold and will not have access to Arev in the future.

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.

The reporting party (RP) stated that 92 year old resident Delora Lovelock DOB: 1/15/24 was residing in the facility from 5/15/2015 to 6/4/2015. Prior to admission the facility was informed that the resident had a broken femur and could not bear weight. The resident required two caregivers to transfer. Initially the facility assessed the resident and accepted her into the facility. Subsequently the resident was not provided the care necessary. The resident was transferred by one caregiver that resulted in the resident's trip to the emergency room where she was diagnosed with contusions to her ribs. The RP stated that prior to admission that the caregivers were trained in transferring resident however the caregiver had no idea how to transfer a resident from bed to

CCIB received SOC 341 reporting that during a meeting with the resident, James Brown (DOB: 09/18/84), social worker from Solano Adult Day Healthcare Center, the resident stated that staff Marco has hit him on multiple occasions. The resident kept repeating that he did not want to return to the facility. RP consulted with resident's previous social worker who affirmed that the resident has a history of making allegations that are not true due. Resident also has a history of Schizophrenia/Delusions. Facility staff stated that the resident has a history of making allegations whenever he is assigned a new social

On March 23, 2017 at 1402hrs, Doctor from Mental Health notified Police Service of a Health Welfare. At 1410hrs, VA police notified the Austin Police Department (APD) and spoke with a dispatcher – 7974 and requested a Health and welfare at 2407 S. 4th street (Green Doors Halfway House) for a possible suicidal Veteran. APD Dispatcher stated he had officer’s en-route to the above address and provided me the incident #170821057.

At 1005 this clinician made contact with the patients CPS caseworker who reports he was scheduled to meet with the son at his daycare. He reports he met with her roommate who made him aware the patient was taken away from the home by ambulance. In addition, the roommate also reported

CCIB Intake received e-mail from John Merrill regarding the initial complaint. The information is the same as the LIC802. LA City Fire Department of the location being problematic due to the number of request for medical assistance. There is a resident who is diabetic and a victim of strokes and kidney failure. He is reported to be in need of care and supervision. He was ordered by the Court to be placed at the location and is assigned to a Probation

CCIB received a Corrective Plan of Action (CAP) detailing the visit to the home on 10/18/17 by Service Coordinator, Sally Cano. Ms. Cano arrived at the home, but no one was there. Ms. Cano proceeded to check Delta Home 3 (located next door) and found 2 of Delta Home Care IV residents along with residents from Delta Home Care 3 at the home. As Ms. Cano was leaving, she observed a bus arrive at the Delta Home Care 2. The bus driver reported that there was no staff at the home and that the residents were waiting outside. It was observed the Delta Home Care 2, 3, and IV to be lacking staff. On 10/19/17, RP and Quality Assurance specialist (QAS) Jesus Ozeda went to the facility to observe the staff to resident ratios and to collect the staff schedules

On November 16, 2017, at 1236hrs, Nurse Supervisor for Desk A and B notified Police service of a sexual assault. VA Police were dispatched to Room 1F340. Upon arrival, I met with Nurse Supervisor who stated that the Veteran had been sexual assault. The Veteran was located in room 1F337, where VA police made contacted the veteran. The Veteran stated that between 0300hrs, and 0400hrs, while at a 1211 old FM 440RD Apt #1-202 Killeen TX, 76549 she was sexually assaulted be a friend. The Veteran informed the VA police that she had not showered and had changed her close. VA Police then notified Austin Police Department (APD) who had an officer respond to the clinic. At 1205hrs, APD Officer arrived on scene and attempted to get the get the Veteran to report the sexual assault to Killeen Police department. At 1337hrs, The Austin Victim Service Counselor arrived on scene and provide information to the Veteran. During this time, it was determined that the Veteran did not want to file a police report about the incident. The Veteran departed the VA Property.

On Friday, September 30, 2016 at approximately 0536 hours, a Black Male Stab Wounds Victim walked into the Emergency Department lobby with a severe Stab wounds laceration to the lower leg and a human bite wound. Security staff was contacted by E.D. triage Nurse Tony Rusiano and escorted the patient to ED room#42. Security conferred with E.D. Charge Nurse, Johnathan Bacal and an E.D. Lock down was initiated at 0538 hours. All Security Officers responded and dispatched over front and back E.D. entrances. Orange County Sheriff's Office was contacted at 0539 hours at which time Security Manager Richard King was informed via text messages along with House Nurse Administrator Sabrina Presley. The patient, Alex James Jones (DOB: 02/03/92 - FIN#86247662) had one severe Knife Wound to the left lower leg and one

On Thursday 12/24/2015 at approximately 2307 hours. Security Officer Omar Alonso (420) was contacted by E.D. Charge Nurse Sharey Selover about an uncooperative intoxicated male patient, Jose D. Gonzalez (DOB: 03/30/1977; FIN# 85006354), come in through the EMS Offload area. Officers Alonso and Ayuso reported to the call and observed an intoxicated male being wheeled into the Special Care Unit (SCU) E.D. room # 39. According to his assigned Nurse Sara Lopez, the patient had been involved in a physical altercation and had been kicked hard in the groin area. Patient did not behave badly or disruptive once he saw that Security were present and his Nurse was able to get his vitals, blood work, and urine without having any issues. Security staff

Reporting party (RP) called CCIB to cross report that resident Gerald Gilliland (DOB: 4/22/41) reported that while he resided at this facility, unknown male staff locked him in a room against his will. It is unclear what room the resident was locked in because resident was unable to convey any details about the room. Resident then stated that it was all of the nursing staff who locked him in the room. Resident was hospitalized at Kaiser South Sacramento on 9/18/16 through 9/22/16 and is currently residing at Eskaton Greenhaven. RP stated that it is unclear if the resident has Alzheimer's or not. RP stated that the original reporting party is Sacramento Sheriff's Department (Report#16-286176) and RP will forward the SOC 341 to CCIB.

CCIB received a SOC 341 via email from Maria Doreen Ainsleigh (medical SW) regarding Terrylee Young (DOB 2/18/1948). RP reported that Terrylee stated that some of the nurses treat her and other residents bad (did not state how). RP reported that Terrylee stated that the staff (names unknown) yells and scream at her and other residents (LPA contacted the SW and Terrylee neither parties could tell me what staff says). RP reported that Terrylee also stated that the Administrator Joe Johnson curses at her and the other residents when they are having problems in the facility. RP reported that Terrylee said that Joe told her on occasion “tough shit” when she has told him about problems. On LPA contact phone call on 3/17/2017, with Terrylee about

On Monday, March 7, 2016 at approximately 0139 hours, FHEO Security Officers were dispatched to room #5109 for a (53D) Disorderly Patient in Medical Unit who was acting in a belligerent manner and attempting to leave his room to go home. I, Steven Evans Shift Supervisor of Security at Florida Hospital East Orlando (FHEO) arrived at 0140 hours along with Officer Thomas Mejia and met with Charge Nurse Michelle Viena and Patient’s Nurse Lisa Guo who were trying to calm down the patient, Ramon Jr. Bermudez (DOB: 05/24/1961; FIN# 85321318), who had been attempting to get out of bed and wanting to leave. Charge Nurse Veina stated that the patient was confused and was not medically clear to leave his bed. Security immediately took control of the situation

CCIB Intake received a call from owner/administrator Therese Kragness who disclosed that the local Law Enforcement was present at the facility. According to the caller, an employee who was having difficulty with her boyfriend received a text threatening to come to the facility. Fearing for her safety, the employee notified Law Enforcement and was escorted to the Police Station to file a restraining order against the boyfriend. Conversely the boyfriend did not appear at the facility. The Administrator will fax the hard copy of the report identifying the employee within the required time