10 COVID-19 deaths at Pulaski facility
Mismanagement cited in state quality report
- Mismanagement at Country Villa Assisted Living exacerbated a coronavirus outbreak that infected 46 people including 10 residents who died with COVID-19, according to state regulators.
A May 28 survey by the Wisconsin Division of Quality Assurance determined the facility in Pulaski failed to adequately monitor residents with COVID-19 symptoms and did not follow public health guidelines until it was too late.
“During the pandemic the (community-based residential facility) did not implement the infection and symptom tracking system identified in their COVID-19 Emergency Plan to monitor for development of COVID-19 among residents,” the report stated.
The survey, obtained by the Green Bay Press-Gazette, continued the investigation that began in May after an outbreak emerged at Country Villa. The division previously ordered owner Chad Reader to submit a plan of correction and pay a fine of up to $700, but increased that amount to $7,600 earlier this month.
Country Villa is barred from admitting new residents until the violations are corrected. The division can reduce the $7,600 forfeiture by 35% if Reader chooses not to appeal the decision.
In an interview Tuesday, Reader said it’s been difficult to lose residents to a “terrible disease” and contended the facility moved quickly to adapt to changing state and federal health guidelines. The facility has now addressed the state’s concerns, he said.
“There’s no perfect answer,” Reader said. “There’s not a book you can read and pick up and make it perfect.”
Records show 28 residents and 18 employees at Country Villa tested positive for the virus — an increase of 10 confirmed cases since the division’s first survey. The facility houses 36 residents total.
The state division, which did not disclose the names or genders of people in the report, determined “a lack of health monitoring” allowed several residents to contract COVID-19.
The 10 deaths accounted for more than one-fourth of the 39 Brown County fatalities linked to the coronavirus.
According to the survey, the first person to succumb to the virus, who had a history of brain trauma, complained of a headache on April 23 but the resident said they felt “very fine.” The director of nursing did not recognize a headache as a symptom of COVID-19 and didn’t follow up with the resident afterward.
The resident was reportedly not eating much, and a caregiver recorded their temperature as 101.6 degrees on April 24. Employees allowed the resident to sit in the main room of the facility both days, the report said.
Reader said the facility isolated residents who showed symptoms and continues that practice today.
The resident was hospitalized on April 26 with low oxygen levels and blue lips and fingers, records show, and died on May 12 from COVID-19 pneumonia.
State regulators found “discrepancies” in where caregivers should have documented symptoms, which allowed the resident’s high fever to go unmonitored, according to the report. The same thing happened to another resident who had a temperature of 100.8 on April 24, tested positive for COVID-19 and later died.
The facility also waited several days to address a resident’s low blood sugar, the survey said. That resident died from COVID-19 complications one week after arriving at the hospital.
Employees faced pressure to work, PPE shortages
The latest investigation bolsters claims from employees who told the Press-Gazette that managers pressured them to work, even when they were sick or showing symptoms.
Multiple caregivers said their supervisors asked them to come in after they disclosed their positive COVID-19 results, according to the report. A caregiver who had not received their results told the nursing director they vomited multiple times and refused to work when the director asked them to.
“The management made you feel like the worst person in the world if you said no,” one caregiver said in an interview with regulators.
Reader called the allegations “completely false,” saying the facility sent home anyone who tested positive for COVID-19 and didn’t ask them to come to work. Employees at the facility who exhibited symptoms stayed until supervisors found a replacement, he said.
“It’s our job to stay there and take care of the elderly until we find a replacement,” Reader said. “We can’t walk out on them.”
Country Villa also did not suspend communal dining and group activities despite recommendations from the Centers for Disease Control and Prevention aimed at helping long-term care facilities prevent the virus’ spread, the survey said. The Pulaski facility utilized social distancing and limited the number of residents in dining and community rooms, but did not require them to eat in their rooms until someone tested positive.
Once the virus took hold, employees had limited access to N95 masks, gowns and other personal protective equipment, according to the report.
“There just was not enough PPE to have for every resident,” a caregiver said. “Gowns had to be hung up in residents’ rooms. We had to use the same gown and disinfect it. Eventually we all got our own N95 by 04/29/2020, but we were expected to keep them and reuse.” +