Brius nursing home secretly discharged resident during government inspection

Did a Brius nursing home discharge a severely physically disabled nursing home resident clandestinely in order to avoid government scrutiny?

A November 2014 deficiency report issued by the Centers for Medicare and Medicaid Services shows a Brius nursing home discharging a disabled resident secretly and without notifying a physician.
Government regulator’s report shows a Brius nursing home discharging a disabled resident secretly and without notifying a physician.

Here are the details as reported by the Centers for Medicare and Medicaid (CMS).

On April 12, 2014, a woman was admitted to a San Diego acute care facility after she was found in her home unable to care for herself. Three days later, she was transferred to Brius’ Clairemont Healthcare and Wellness Centre.

According to the facility’s assessment of the resident, she was unable to walk or move about, and was dependent on staff for nearly all of her needs due to physical limitations affecting both of her arms and legs. The woman also had several medical illnesses and complications — diabetes, high cholesterol, nerve pain, muscle spasms, etc. — requiring regular and consistent monitoring and medications as part of her care.

On the morning of September 9, a team of government inspectors entered the nursing home to conduct a comprehensive review of the facility. While the inspection team was surveying the nursing home its administrator, for reasons not made clear in the report, ordered staff to discharge and remove the woman from the nursing home, seemingly in haste. A staff member, uneasy with the orders, approached a nursing home social worker about her misgivings. The social worker told the staff member that “a cab was coming for Resident A and that the cab would pull around to the back of the facility and that they would sneak Resident A and her belonging[s] into it.“

The woman was wheeled to the rear of the nursing home — a move one staffer described as “unusual” — removed from her wheelchair, and placed into a cab that was waiting to take her to her trailer home. The nursing home released her without notifying a physician. She did not have the means to care for herself and had a urinary catheter still in place.

Three nursing home staff members, who were following behind the cab in a private car, expressed to each other their discomfort with the situation. They knew what they were doing was not right. Their concerns grew when they saw the state of the woman’s trailer. The trailer was filthy; one staff member struggled to keep from vomiting. Despite their misgivings, they laid her on the bed and departed, leaving her unattended — without a phone, without medication, and without food.

Just a few hours later, in response to a neighbor’s phone call, police officers arrived at the trailer to find the woman still in her bed and in need of immediate medical attention. The officers took her to an emergency room where medical staff found that the nursing home had failed to remove the woman’s catheter. The catheter bag was full, its tubing was clogged, and the woman smelled strongly of urine and feces. She also had two severe pressure ulcers on her foot.

One month later, responding to a complaint about this incident, CMS issued the nursing home a “Level 4 Immediate Jeopardy,” the agency’s most severe deficiency.

This and other instances of deficient care at Brius facilities prompted California’s Department of Public Health, in July 2016, to deny Brius’ application to operate five more nursing homes in the state based on the company’s repeated failures to comply with established rules and standards governing California’s skilled nursing home industry.