A registered nurse blew the whistle on a Brius nursing home outside Los Angeles, triggering a state investigation that revealed management failing to report serious falls and a choking death, asking workers to alter their records to avoid trouble with state regulators and leaving patients unsupervised for extended periods of time.

Following the nurse’s complaint, California’s Department of Public Health launched an investigation into Lakewood Healthcare Center in Downey. In February, state officials hit the nursing home with six Class A citations, four Class B citations and $156,000 in fines.

Responding to the complaint, investigators arrived unannounced at the facility at 5:45 a.m. Nov. 5, 2018, to a grim scene.

“The floors were observed with black stains, call lights were ringing without staff responding, a foul strong ammonia odor permeated throughout the hallways, residents’ were yelling and there were no staff members around,” investigators wrote.

Following an interview with one nurse, the investigators learned that: 

1. Recurrent falls not reported timely to the physician and care not provided.
2. The nurse-patient ratio did not meet the criteria to care for residents’ needs.
3. Reports of incidents, body assessments, and nurses’ notes were being removed from the clinical record by the director of nursing.
4. Residents with difficulty swallowing were provided with a honey bun causing one choking death and a second resident hospitalized after choking on the honey bun.
5. Residents were left unsupervised, wet, and soiled for extended periods of time.
6. The director of nursing had asked the licensed nurses to change their documentation because she did not want to get in trouble with the department of health.

Moreover, one nursing assistant told investigators that the director of nursing and administrator told staffers that they would lose their jobs if they spoke to state authorities.

The citations were hardly the first black mark for Brius or the Lakewood Healthcare Center.

Since 2016, the California Department of Public Health has received 315 complaints and facility reported incidents on Lakewood, while issuing it 164 deficiencies and 29 citations (state fines), according to research by California Advocates for Nursing Home Reform.

Last year, a California state audit found that Brius had the worst patient care record among California’s three largest nursing home chains, racking up .52 citations per 100 nursing home beds – nearly double the company’s two leading competitors.

Four of the Class A violations at Lakewood involved residents who were injured from falls. One resident who needed one-on-one care fell and his head on the headboard of his bed while left unattended. The impact resulted in a broken nose and bleeding in his brain, resulting in a four-day hospital stay. The other two involved the residents who choked on the honey buns. Management didn’t report either choking incident to state authorities.

Regulators also cited Lakewood for impeding their investigation. Investigators claimed that management denied them access to facility records and that key notes about the falls and choking episodes could not be found.

The facility was also cited for actively impeding the DPH investigations. Investigators were denied requested records for hours. The DON stated that facility incident records, IDT progress notes and the nurses’ notes about the fall incidents and choking episodes were not in the residents’ clinical records and were nowhere to be found.