ASPEN - STATE - 2567 - Everybody Is Scared To Speak Up

3/20/24, 11:49 AM ASPEN_STATE_2567
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California Department of Public Health
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X1) MULTI

AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
A. BUILDIN
93000032 B. WING: _
NAME OF PROVIDER OR SUPPLIER
PACIFIC GARDENS MEDICAL CENTER 215

Haw
(X4) ID PROVIDER'S PLAN OF CORRECTION SUMMARY STATEMENT OF DEFICIENCIES ID

PREFIX (EACH CORRECTIVE ACTION SHOULD BE (EACH DEFICIENCY MUST BE PRECEDED BY FULL PRE
TAG CROSS-REFERENCED TO THE REGULATORY OR LSC IDENTIFYING INFORMATION) TA
APPROPRIATE DEFICIENCY)
A000 Initial Comments A000
The following reflects the findings of the

California Department of Public Health during
the investigation of a complaint.
Complaint number: CA00730081
Representing the California Department of

Public Health:
Surveyor 43236, Health Facilities Evaluator
Nurse
Surveyor 28045, Health Facilities Evaluator I
The inspection was limited to the specific

complaint investigated and does not represent
the findings of a full inspection of the facility.
One deficiency was issued for complaint

number CA00730081.
A040 1278.5(d)(2) Health & Safety Code Section A040 04/2

1278.5
(d)(2) For purposes of this section,

discriminatory treatment of an employee,
member of the medical staff, or any other
https://www.cdph.ca.gov/Programs/CHCQ/LCP/CalHealthFind/Pages/ASPEN_STATE_2567.aspx?EventID=7SK911 2/10
3/20/24, 11:49 AM ASPEN_STATE_2567
health care worker includes, but is not limited
to, discharge, demotion, suspension, or any
unfavorable changes in, or breach of, the
terms or conditions of a contract, employment,
or privileges of the employee, member of the
medical staff, or any other health care worker
of the health care facility, or the threat of any of
these actions.
This Statute is not met as evidenced by:

Based on interviews and record review, the
facility failed to follow their policy & procedure
by terminating registry staff contracts early for
communicating patient safety concerns to the
Department of Public Health (DPH) for five of
13 sample selected Registered Nurses (RN 1,
RN 2, RN 3, RN, 4 and RN 8).
This deficient practice had the potential to

reduce available licensed nursing staff to
provide patient care.
Findings:
An unannounced on-site visit was conducted,

on 3/23/2021 at 9:10 a.m., to investigate a
complaint regarding registry nurses being
terminated for voicing grievances to hospital
administration and communicating with the
DPH during a previous unannounced on-site
visit on 2/24/2021.
During a telephone interview, on 3/23/2021 at

11:10 a.m., with RN 1, he stated, "They
terminated my contract, I assuming because
we talked to you guys. We were cancelled on
March 5th. They brought us into the office and
said they were cancelling us because of low
census, but the hospital has been closed the
entire time we've been there." RN 1 also stated
that he was told the terminated nurses were
chosen at random, but both he and his wife,
RN 2, were terminated.
During a review of RN 1's registry contract,

dated 1/22/2021, indicated RN 1's contract
began on 2/1/2021 and will end on 3/27/2021.

11:13 a.m., RN 2 stated on 2/24/2021, "The
nurses spoke to DPH in the Chief Nursing
Officer's office and they had names they knew
3/20/24, 11:49 AM ASPEN_STATE_2567
Officer s office and they had names, they knew
who it was."
During a review of RN 2's signed declaration,

dated 3/4/2021, indicated, "Due to the lack of
reasoning given related to our contracts being
'canceled' or us being 'sent home', the
overwhelmingly obvious confusion between
our staffing company and Emergency Medical
Services Authority (EMSA), and the multitude
of issues we have witnessed and been
whistleblowers for, we feel that if this is truly a
'cancellation' of our contract, then it is a direct
result of retaliation from the administration and
leadership at the facility. I have been an
Emergency room nurse for more than 5 years
and have never experienced a situation
remotely close to what is taking place at this
facility. I have left every staff position and
contract assignment in good standing with my
leadership and employer's. RN 1 has been an
Intensive Care Unit (ICU) nurse for more than
13 years, with extensive experience in
leadership and management roles as an ICU
director and clinical supervisor. RN 1 has also
left every staff position and contract
assignment in good standing with his
leadership and employer's."


11:52 a.m., RN 3 stated on 2/26/2021, DPH
was again present at the facility, but prior to
them arriving, nurses were sent home. RN 2
stated, "I said I'd like to stay because I have
other concerns to bring up to DPH. The
Director of Nursing instructed me to go home
and pack my stuff. So, I left and found out that
other nurses had been sent home that day too.
The nurses that had spoken up or voiced
concerns had been sent home." RN 2 further
stated, "I fully believe that my contract was a
direct retaliation of us because we spoke up.
They specifically blamed the select few nurses
who had concerns of patient safety."
During a review of RN 3's signed declaration,

dated 3/4/2021, indicated, "February 24th, . . .
We were then told DPH had come back to the
facility and we were given an opportunity to go
speak to them about our concerns. When we
3/20/24, 11:49 AM ASPEN_STATE_2567
went in, we had discussed everything that we

had felt that made the facility unsafe not only
equipment wise, but preparation wise (i.e.
management/leadership and policies and
procedures) . . . Later that afternoon, an EMSA
Representative arrived at the facility and spoke
to a few of us nurses outside to discuss what
had been happening and what our concerns
were. . . We also then presented that we didn't
feel comfortable bringing up our concerns to
the core organic staff and leadership at the
facility because we didn't trust them due to
their previous actions of accusing the travel
nurses and blaming us for all of the problems
at the facility."


12:28 p.m., RN 4 stated, "People that were
more vocal were definitely sent home. They
just didn't want me at the facility so they would
have me not be in the building. They didn't
want the state to approach me and ask me
questions."

12:56 p.m., RN 8 stated that as the night shift
nursing supervisor, she brought up concerns'
multiple times to hospital administration. On
3/10/2021, she received a text message from
the Director of Nursing saying that her services
were no longer needed.

dated 2/12/2021, indicated that RN 4's contract
began 2/14/2021 and will end on 3/31/2021.
During an interview, on 3/23/2021 at 8:19 p.m.,

RN 5 stated, "I know that there have been a
few incidents where people have brought up
concerns and have gotten fired. I don't think
one shift or the other is immune to that. Two
weeks ago, two people got fired, they brought
up multiple concerns during a meeting . . . I
think the next morning they were asked to not
return."

RN 6 stated, "The culture is if you voice your
opinion, you stand out. If you stand out, you
get canned E er bod is scared to speak
3/20/24, 11:49 AM ASPEN_STATE_2567
get canned . . . Everybody is scared to speak
up . . . They did not say that they were gonna
cut you, but people who have been majority
speaking up get cut. The next day, I don't see
them anymore."

RN 7 stated, "We can't say anything. We will
have meetings, and no one will say nothing . . .
I called my recruiter and they stated the
hospital is supposed to contact us and give us
two weeks' notice. If they send you home, call
me. We are supposed to know in advance
when your last day is.' They were in the dark
too.
During a review of the facility's policy &

procedure (P&P) titled, "Policy Title: Grievance
Procedure," reviewed 1/6/2021, indicated,
"Taking a problem to the employee's
supervisor or appealing to a higher authority
will not jeopardize the employee's job, pay or
the manner in which the employee is treated.
The employee should report immediately any
reprisal to the Human Resources Department
or the Chief Executive Officer."
Licensing and Certification Division
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
STATE FORM 6899 If continuation sh

7SK911
3/20/24, 11:49 AM ASPEN_STATE_2567
Page Last Updated : December 21, 2017

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3/20/24, 11:49 AM ASPEN_STATE_2567

California Department of Public Health

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X1) MULTI

NAME OF PROVIDER OR SUPPLIER

PACIFIC GARDENS MEDICAL CENTER 215

(X4) ID PROVIDER'S PLAN OF CORRECTION SUMMARY STATEMENT OF DEFICIENCIES ID

A000 Initial Comments A000

The following reflects the findings of the

Complaint number: CA00730081

Representing the California Department of

The inspection was limited to the specific

One deficiency was issued for complaint

A040 1278.5(d)(2) Health & Safety Code Section A040 04/2

(d)(2) For purposes of this section,

This Statute is not met as evidenced by:

This deficient practice had the potential to

An unannounced on-site visit was conducted,

During a telephone interview, on 3/23/2021 at

During a review of RN 1's registry contract,

During a telephone interview, on 3/23/2021 at

During a review of RN 2's signed declaration,

During a review of RN 2's registry contract,

During a telephone interview, on 3/23/2021 at

During a review of RN 3's signed declaration,

went in, we had discussed everything that we

During a review of RN 3's registry contract,

During a telephone interview, on 3/23/2021 at

During a telephone interview, on 3/23/2021 at

During a review of RN 8's registry contract,

During an interview, on 3/23/2021 at 8:19 p.m.,

During an interview, on 3/23/2021 at 8:35 p.m.,

During an interview, on 3/23/2021 at 9:02 p.m.,

During a review of the facility's policy &

Licensing and Certification Division

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

STATE FORM 6899 If continuation sh

Page Last Updated : December 21, 2017

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