At least 20 nursing assistants who were blocked from working with the elderly by one state department were cleared to perform similar roles by another department, according to a report released by the Senate Office of Oversight and Outcomes.
The report issued Friday found that the lapses occurred in spite of a 2006 law that mandated cross-checking between the departments.
The law was passed in the spirit of avoiding scenarios like this one, which is laid out in the report:
A San Diego certified nurse assistant ran into trouble in 2006 when she tried to transfer an 81-year-old nursing home resident from her bed to the shower. The resident’s chart stated that two nurse assistants should always work together to move her to avoid a fall. But A.L. did it herself. When the resident fell, A.L. failed to tell a supervisor. She later told investigators that the patient, with a history of dementia, seizures and strokes, had not fallen. A.L. said she had merely “eased her onto the floor” when she could no longer support her weight.
The fall fractured the woman’s left hip. Two months later, she died. “Unquestionably, this incident contributed to her demise,” a report by the Department of Public Health concluded.
A.L. was fired. Later, she pled guilty to a criminal charge based on the incident. The Department of Public Health revoked her nurse assistant certification. The nursing home was cited by the state, and the family of the resident sued.
A few months later, however, A.L. was back working with aged Californians. She was cleared by the Department of Social Services, which was unaware of her history as a nurse assistant, to work as a caregiver at a different type of residential facility for the elderly. She continues to work there today.
It would be an exaggeration to say that the worker slipped through the cracks. Rather, the state department in charge of setting up a database that would have headed off such a scenario left the door wide open, according to the report.
The Department of Social Services was mandated to create the system under the 2006 law, but:
Four years later, the database does not exist. The Department of Social Services decided in the 2007-08 fiscal year that it would not seek money to comply with the new law, which was contingent on a budget allocation. In later years, as the state’s budget deteriorated, Social Services did not consider seeking money for the centralized database, estimated to cost “in excess of $500,000.” Nor did it inform the Legislature that the database would not be built, deciding on its own that the state’s cash crunch would mean shelving the project while it pursued less costly steps.
The failures to report will be the subject of a hearing set for March 24 in front of the Senate Subcommittee on Longterm Care and Aging.
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