Photograph by Dai Sugano
When representatives from the Los Gatos Weekly-Times visited Guardian of Los Gatos at the corner of Los Gatos Boulevard and Samaritan Drive, they found the facility spic-and-span.
Veteran's journey leads to nursing home
Saratogan's experience uncovered during D.A.'s three-month investigation
By Jason Baker
Stanley Elsworth Spencer was a war hero. While serving on a U.S. Navy submarine during World War II, he placed his life in harm's way, fighting to preserve his nation's freedom. He returned from the war to live a long life in Saratoga.
But though Spencer eluded capture at sea during the war, his son Jeff Spencer said that had his 74-year-old father been captured and found in an enemy POW camp in the condition in which he was found at the Guardian Los Gatos nursing facility in July 1996, it would have been viewed as a "crime against humanity."
"I was infuriated. I could not believe how my father had been allowed to deteriorate," he said. "And everyone acted like this was all normal."
A citation of complaint from the state Department of Health Services delivered against Guardian Postacute Services Inc. of Northern California, the parent company of Guardian Los Gatos, details the findings of state evaluators in the case of Stanley Spencer. Investigators discovered the case during a three-month criminal investigation prompted by allegations of patient neglect at Guardian Los Gatos, which led to a Santa Clara County criminal grand jury indictment on May 25 against Guardian Post Acute Services Inc., on six counts of neglecting elder and dependent adults. The charges stemmed from documented cases of substandard care given six patients, ranging in age from 37 to 82, at three of Guardian's facilities in Los Gatos and San Jose dating back to 1996.
State regulators had fined Guardian $30,000 over the Stanley Spencer case, and ordered the facility to establish a plan to comply with regulations. Robert Peirce, chief executive officer of Guardian Health Group, said the company did not appeal the fine, but that the fine was later reduced to about $16,000 after further reviews by the state. He declined to comment on whether or not any Guardian employees were terminated as a result of the case. "I can say that we have strengthened management at the facility and the evidence is crystal clear that we have a much improved performance as a result," he said.
Department of Health records show Spencer was admitted to Guardian Los Gatos on July 11, 1996, to recover after a hip replacement. He also was suffering from pneumonia, cardiovascular accident, hypertension, peptic ulcer disease and chronic alcohol abuse, records show. Health records show Spencer was "alert, oriented, with periods of confusion, continent of bowel, but incontinent of bladder, for which he had a foley catheter in place." Nurses also documented three pressure ulcers, one on the heel of each foot and one on his lower back , near his right buttock. A physician ordered that the ulcers be cleansed, covered and dressed until they healed.
On July 18, Guardian staff in the facility's Pressure Evaluation Report noted the changes of the three ulcers. The ulcers in both the left and right heels had increased in size, and the right heel had developed necrosis, or death of body tissue. The facility's policy and procedure for pressure ulcers with a necrotic area ordered employees to "notify the physician for possible ... treatment to clean the wound. Only after the wound was clean and free of necrosis apply a Hydrogel pad as appropriate."
Records show no documentation that the physician was informed of the advanced stage of the ulcer nor was any change of treatment noted.
Also the same day, records show nurses noted Spencer had loose bowel movements, but no assessments were documented for possibly increasing his hydration related to diarrhea or vomiting.
On July 26, records show nurses documented Spencer having a fever of 100.7 degrees. It was then that the physician was informed that the treatment for the pressure ulcers was "ineffective." The doctor started Spencer on antibiotics treatments and "Santyl Collagenase," an agent for debradement in the pressure ulcers.
About 2:30 p.m., July 27, Jeff Spencer said he came to visit his father at Guardian. He had seen his father just four days earlier and said at that time his father was doing fine and looking forward to leaving the facility. "I entered his room and was overwhelmed by the unbelievable stench. Three orderlies were attempting physical therapy on my father, but he was completely incoherent," he said. "His eyes were glazed, and he could only communicate with grunts and growls. I was really astonished. After only four days, I wasn't ready for such a decline."
Spencer said he sat down while the orderlies continued, and noticed that his father had excrement caked on his back.
According to records, when nursing staff were called to the room, they found Spencer suffering from "left side weakness." The physician was notified, and ordered Spencer transferred to an acute hospital for the evaluation of a possible stroke.
According to hospital records, blood tests performed on Spencer showed a strong indication of infection. Cultures taken were positive for the growth of multiple organisms, including pseudomonas, which is known to produce strong odor.
Physicians also diagnosed Spencer with severe dehydration, and stated that the infections developed in the pressure sores on the lower back were attributed to contamination from feces and urine. The pressure ulcers required surgery, and a statement from the surgeon in the records stated, "the necrotic wounds in this patient were attributed to the lack of pressure-relieving measures, such as frequent turning or repositioning."
Jeff Spencer said his father died six months after his stay at Guardian Los Gatos. "All I can say is that he did not recover," he said.
State health investigators in September found that Guardian "failed to continually assess that patient's needs of adequate hydration when the patient's care plan already had identified the risk factors related to the fluid needs, such as pressure ulcers, immobility due to recent hip fracture, and compromised nutritional needs. When the pressure ulcers advanced and necrosis (death of the body tissue) developed in the patient, the facility failed to inform the physician immediately to change the treatment modality as per the facility's policy's and procedures. Consequently, the patient developed infections in the pressure ulcers and severe dehydration that resulted in a life-threatening situation requiring aggressive medical intervention."
Peirce told the Weekly-Times that he could not speculate as to why the district attorney's office chose to do what he called "retroactively criminalize" incidents that had been addressed through state policies and regulations. Of the state health deficiency logged against Guardian Los Gatos, Peirce said most of them occurred in the midst of a $1.8 million facility renovation. He estimated Guardian had paid about $100,000 in deficiency fines to the state based on incidents occurring between July 22, 1996, and July 16, 1998, the time frame of the cases used by the district attorney's office.
Payment (of fines) does not suggest an admission of fault; it simply is how the system works, he said.
While owned by the Alta Bates medical group in Berkeley, Guardian was a nonprofit operation. The current ownership converted it to for-profit status. The corporation has invested more than $10 million in improving its facilities since 1994, including renovations to Guardian Los Gatos.
The outcome of the indictments could affect nursing home regulations throughout California, according to Pat McGinnis, executive director of the California Advocates for Nursing Home Reform. The case is unique in that criminal charges were brought directly against the health-care corporation, not against an individual facility.
"It's hard to tell, but I think that when a corporation itself has been criminally indicted, everyone will tend to pay more attention," said McGinnis. "It could have a major impact."
Los Gatos, California Since 1881
