As lawyers that sue nursing homes, we are always looking for facilities with plagued with abuse, neglect, falls, bedsores and lately, outbreaks of deadly Candida auris. Usually when we find a nursing home with such serious problems we quickly learn they have a terrible history with the Centers for Medicare and Medicaid Services (CMS) and state regulatory authorities. Poor patient outcomes go hand in hand with poor inspection reports. Suprisingly, that isn’t the case with the Garden Park Care Center in Santa Ana, California.
Garden Park has good ratings. Unfortunately, it takes just one simple mistake to lead to a deadly outcome.
Regular readers of this blog know we always push would be nursing home residents and their families to use the free Medicare Compare tool made available by CMS. Look up Garden Park Care Center and you will find it has a five star “Much Above Average” rating. How is it, then, that the California Department of Public Health identified it as one of eight facilities where deadly Candida auris was found.
We think we know the answer.
Because of patient confidentiality, we don’t know how many people at Garden Grove were infected by C. auris. If there is just one, that can happen at any facility or hospital anywhere in the world.
Candida auris is a deadly fungus. It wasn’t found in the United States until 2015. Since then, there have been over 800 cases in the U.S. When older patients or those with compromised immune systems are infected, the mortality rate soars to over 50%. That is because there is no known cure.
The Centers for Disease Control and Prevention call Candida Auris a global health threat.
According to the CDC, C. auris:
- Is often multidrug-resistant, meaning that it is resistant to multiple antifungal drugs [It is considered a “superbug],
- Is difficult to identify with standard laboratory methods, and it can be misidentified in labs without specific technology. Misidentification may lead to inappropriate management, and
- Has caused outbreaks in healthcare settings. For this reason, it is important to quickly identify C. auris in a hospitalized patient so that healthcare facilities can take special precautions to stop its spread.
Outbreaks are more common and more widespread in nursing homes and less so in hospitals. [We have extensive information about this fungal infection on our cornerstone Candida Auris patient information page.]
Garden Park Care Center and Candida Auris
Garden Park Care Center is a for-profit skilled nursing facility located in Santa Ana, California. Like the other 7 facilities with confirmed Candida Auris infections, all are in Orange or Los Angeles Counties.
As noted previously, Medicare gives the facility a five star rating. Look a bit deeper at the inspection reports, and a few cracks emerge. We will explain in the paragraphs below but first, let’s look at what we know.
We know there have been 180 confirmed cases of Candida Auris in California. All but 4 were this year.
Based on extensive research by the CDC, we also know that C. auris spreads primarily through direct contact. Poor sanitation practices allow this deadly fungus to quickly spread through a facility.
Although Garden Park has high marks for its health inspection ratings, earlier this year the facility was cited for its failure “to implement appropriate infection control practices.”
According to the report,
- The facility failed to ensure the isolation signage was posted in front of an isolation room, and 2)
- The facility failed to properly clean and disinfect reusable resident care items to ensure they were clean before being used.”
These failures pose a serious the risk of cross contamination. If the cross contamination involved a common cold, no one would get overly upset if the cold spread because of improper sanitation and isolation protocols. But when a patient is isolated because of Candida Auris, poor sanitation can lead to an outbreak and have deadly consequences.
Remember, the people most at risk of a fatal outcome are those with compromised immune systems, the very population often found in a nursing facility.
The investigation giving rise to the finding of poor infection control practices began when a Licensed Vocational Nurse was observed handling the isolated patient’s medication with her bare fingers and using a stethoscope on the same patient’s bare skin.
The nurse then went on to a different room and handled another patient’s medication and didn’t sterilize the stethoscope or use gloves.
Before putting all the blame on the nurse, the sign on the isolated patient’s door didn’t say why the patient was isolated or what precautions were to be observed.
When confronted with the violations, the nurse admitted she did not think about gloving up or following proper hygiene at the time. She also verified her failure to clean and disinfect the stethoscope between residents in isolation.
A small mistake can lead to a deadly outbreak.
Other Safety Issues at Garden Park
We aren’t picking on Garden Park. Medicare and the State of California are quite rigorous in their inspections and monitoring. We are sure that the facility earned its overall high rating. The theme of this post is more that anyone can make a mistake. But in a healthcare setting, those mistakes often have dire consequences.
One of our biggest peeves are bedsores also known as pressure ulcers. They cause tremendous pain and suffering, can delay the healing process by months and are completely preventable. In advanced cases, bedsores can be fatal. [See our bedsore information page to learn more.]
Earlier this year during a different inspection, Garden Park failed to “provide appropriate pressure ulcer care and prevent new ulcers [bedsores] from developing.” That is senseless and inexcusable.
In fairness to the facility, the patient was found to have a stage 2 pressure ulcer upon admission. The inspection noted, however, that the ulcer got worse and on multiple occasions the patient didn’t receive any treatment or had improper treatment.
One nurse was observed touching several environmental surfaces after putting on surgical gloves but before touching the patient’s open wound. So why bother with gloves? (Remember, this incident happened in a facility with a known colonization of deadly Candida auris.)
Garden Park’s Staffing Issues
In our own investigation, we often find that poor staffing, poor pay and poor staff training greatly contribute to poor patient outcomes. Look beyond the overall rating of Garden Park and you will find that Medicare gave the facility a below average rating for staffing.
Poor staffing almost always means corners are cut. When staff is overwhelmed, basic sanitation and hygiene often is the first thing to be ignored.
Seeking Nursing Home Residents Suffering from Candida Auris
We are actively seeking out patients and families of loved ones who have suffered or died because of Candida Auris. No nursing home can prevent an isolated case of a superbug. The transmission from patient to patient of this particular bug is easily preventable, however.
Based on public documents, it appears that Candida auris has been found at Garden Park Care Center. While every case is unique, we are ready to investigate outbreaks anywhere in the nation. If the infection can likely be traced to poor sanitation, failure to test or understaffing, you may have a claim for damages.
People go to nursing homes and rehabilitation centers to either get better or spend their final years in reasonable comfort. They don’t go to die from something easily preventable.
For more information, we urge family members to visit our nursing home abuse page. Ready to see if you have a case? Contact us online, by email [hidden email] or by phone at 833-201-1555. There is no obligation and we never charge a fee unless we win.