Emails show Brighton Gardens, where 17 have died of COVID, drew scrutiny over PPE use
Johnson County’s health director was so concerned with a jump in COVID-19 cases at a Prairie Village nursing facility that he asked first responders what they had experienced inside.
Emails obtained by The Star through an open records request show that Dr. Sanmi Areola contacted the county’s consolidated fire department late last month. In an effort to pinpoint changes needed at Brighton Gardens, he wanted to know what responding officers had noticed and get their perspective on how cases were being handled.
“It is not very often that we see DHE ask Fire/EMS for feedback, so let’s make a legitimate effort to provide any applicable, objective feedback we can!” wrote Steve Chick, J., deputy chief of the Consolidated Fire District No. 2. “... Looking for ANY objective observations that we can share to help them help Brighton Gardens control their current situation.”
Since the pandemic began, Brighton Gardens has had more cases and deaths than any nursing and assisted living facility in Johnson County. The facility has gone from 21 cases and 3 deaths on April 24 to 83 positive tests — a combination of residents and staff — and 17 deaths as of Friday.
A state investigation released to The Star Thursday shows that an onsite inspection of Brighton Gardens earlier this month uncovered several violations, including errors in the facility’s screening procedures that allowed employees with coronavirus symptoms to work.
Families with loved ones at the facility have complained about a lack of transparency and have been frustrated with the spread of cases . They’ve also questioned whether there was enough personal protective equipment and why there wasn’t more testing of residents and workers in April.
“The increasing number of cases were concerning,” Areola told The Star in an email Thursday. “When case numbers at Brighton Gardens rose, extra efforts were made to take a closer look at where processes could be improved and guidance was given.”
On May 1, the fire chief emailed the health director with observations from two officers who had run “Covid calls” at Brighton Gardens. A lieutenant explained what he had seen during a call.
“The one observation that I noticed was that gloves and gowns were not changed from pt. (patient) to pt. (patient) room,” wrote Lt. Dustin Prothe in an email to his superior. “I never saw them change.”
A captain noted that staff at the facility had not placed masks on the two coronavirus patients he had been involved in helping.
“He felt intuitively that they could have been more aggressive with masking patients, if they had the masks on hand to do so,” the deputy chief wrote of the captain. “And that might help reduce the overall spread as those patients are transported through the facility.”
Chief Tony Lopez told Areola: “We are sharing these comments and observations to be helpful in combating the further spread of this virus in our community and are in no way trying to disparage the work that the Brighton Gardens’ staff is performing.”
The supply and use of protective equipment at Brighton Gardens was highlighted in other emails.
In addition, a worker who spoke to The Star said some staffers received their first training on PPE this past week and that on two occasions, from mid to late April, employees were asked to use the same mask for a seven-day period. The supply of gowns, the worker said, had gotten dangerously low last month and the facility was in need of more hand sanitizer.
Elizabeth Holzschuh, an epidemiologist with the Johnson County Department of Health and Environment, emailed colleagues about the facility’s needs on April 28.
“Hey all — as you have probably read, Brighton Gardens (a LTCF) has been having an outbreak of COVID, which has now spread to all of their wings/units,” Holzschuh wrote. “They say they’ve been filling out the PPE survey, but are still short on gowns and hand sanitizer in particular, although gloves are going to be a need soonish. They are all set with masks. Is there any way to move them to the front of this line?”
Several cases of gloves and hand sanitizer arrived the next day.
Before they were delivered, Brad Mason, deputy chief of Johnson County Med-Act, emailed the director of Brighton Gardens. Mason said there appeared to be “some confusion regarding your needs.” Someone at the facility had told the county that morning that the need was for gowns, nothing else.
“The County is ready to support your needs the best we can,” Mason wrote. “We hope to have additional PPE received in the coming weeks and will make this available. Please understand that accuracy in reporting your PPE needs on a weekly basis is very important to our process. ... Please stay safe!”
Denise Falco, regional vice president of operations for Sunrise Senior Living, which owns Brighton Gardens, told The Star Friday that the Prairie Village facility has sufficient PPE supplies at this time.
“We quickly developed and introduced new training to guide our teams through appropriate PPE use,” Falco said in an emailed statement, “and regularly in-service and coach our teams with learning opportunities to help ensure consistent compliance.”
Ombudsman wanted answers for families
The cries about Brighton Gardens grew louder late last month. Emails show that during the last week of April, there were many demands for answers and solutions.
On April 30, as the facility was struggling to contain the virus and cases had grown to 32 with six deaths, a regional ombudsman who works in the state office of administration sent an email to the facility director, Lisa Barnes.
“I cannot tell you how many calls I have been getting from family members since they saw the last update asking questions, I just can’t answer,” wrote Christine Mozingo, Kansas’ Region 3 long-term care ombudsman. “Could you tell me please, are all residents being tested? If not, why? ... The families of course are concerned by the doubling of cases. What is being done to prevent the spread?”
Mozingo asked a total of eight questions, her urgency and frustration evident.
“Any answers you can provide would be greatly appreciated,” Mozingo wrote to Barnes. “Many families do not feel confident hearing it from you I’m afraid, as they feel the facility was not transparent and so they are turning to me.”
Mozingo didn’t stop there. At 5:25 that same day, she forwarded that email to the Johnson County health department. Again, she asked for help to understand what was happening inside the Prairie Village nursing facility.
“Can you possibly help to answer any of the questions below?” the ombudsman asked the health department. “I have reached out to the facility and they have to send to their attorneys before they will send any answers in writing. ... I just have a lot of families who are concerned about this turning into a Riverbend situation and are just wanting some answers to what they consider are some basic questions.”
Riverbend Post Acute Rehabilitation is in Kansas City, Kansas, and since April 1 it has been overwhelmed with COVID-19. The facility has had 132 cases of the coronavirus and 36 deaths.
Mozingo told The Star last week that she never heard back from the health department.
It was on April 30, though, that the health director told Johnson County commissioners that his staff had been working with Brighton Gardens to try to contain the virus. Areola said he just had authorized roughly 230 kits for the facility so all residents and staff could be tested. And, he said, that would be repeated in another week.
Hours before that meeting, Areola had replied to two commissioners and a state legislator who had questions regarding the Prairie Village facility. He told them that his department had engaged Brighton Gardens to “better understand the challenges that they may be having as we do for every outbreak.”
Areola told them that a fellow with the U.S. Centers for Disease Control and Prevention had gone to the facility with a county health official the weekend before. The fellow had some suggestions for the staff, but she had concluded that they had been doing things things the correct way, the health director said.
“However, as they were leaving the facility,” Areola wrote in the email, “a staff member came to them and alleged the facility has not been following protocol. This was reported to KDHE and KDAD. “
Areola said his office would be doing a surprise visit to Brighton Gardens that day.
‘Begging for tests’
Carole Munns worked as a physical therapist assistant at Brighton Gardens from 2012 to 2017. She said she had such love and faith in the facility that she eventually moved her parents there and her mother still lives in assisted living at the Prairie Village facility.
As Brighton Gardens faces scrutiny over the coronavirus, Munns said she believes the facility “has gotten a bad rap.”
She said she’s counted nine emails she’s received from facility administrators since mid-March and that they have done everything they can to keep families aware of the rising number of coronavirus cases.
Her concern is that there weren’t enough tests early on.
“We were begging for tests a lot sooner,” Munns told the Star. “When I called and asked why can’t you test everyone in the building, (the director’s) response was they had asked for the tests for all and felt they were being ignored and they could only get tests for symptomatic people.
“I feel if they they had gotten the tests early on when they wanted, some of these deaths and cases could have been prevented.”
Falco said Friday that administrators with Brighton Gardens have followed the local health department’s guidance on COVID-19 testing. Initially, the department supplied “very limited test kits” and “guided us to complete random testing among those who were symptomatic only,” she said.
“Given the limited testing available, we contracted with an independent lab to test patients and team members in our skilled nursing neighborhood in mid-April,” Falco said. “We then expanded to whole-home testing in assisted living and memory care following new guidance from the department of health as more testing was made available.”
The health department has said that testing supplies were difficult to obtain in early April. Priority was given to those who were symptomatic, health officials said.
“JCDHE offered testing supplies to all LTCF (long-term care facilities) initially,” Areola said. “... When the number of cases increased (at Brighton Gardens) JCDHE strongly recommended that all staff and residents be tested. We worked with their corporate office to get that done.”
Pamela Peck’s 96-year-old mother lives at Brighton Gardens. She’s healthy and has not contracted the coronavirus.
“I know they are really trying,” Peck said. “It just seemed to be very sudden and very intense. So they have come under scrutiny.
“I just want people to know there are those of us who have known these people for years and know they are devoted to doing the right thing and I think they are making progress. I hope that that side of it is presented.”
Failed to follow protocol?
This past week, Gordon Grohman Jr., the son of a Brighton Gardens resident, sued the facility. His father, Gordon Grohman Sr., contracted the virus there and died earlier this month.
According to the suit, filed by Attorney Rachel Stahle, the elder Grohman — who was 88 — hadn’t eaten in several days because of a loss of his sense of taste, which is a symptom of COVID-19.
By April 29, Grohman was confused and exhibiting several signs of the virus, the suit said. At that point, his family had to insist that Grohman be transported to a local hospital, Stahle said.
The next day, while at the hospital, he was diagnosed with the coronavirus.
On May 1, Grohman Sr. died.
“There is evidence that they (Brighton Gardens) failed to follow proper infection control protocol and utilize PPE that was available,” Stahle told The Star.
The suit said that defendants — including Barnes, the facility director, and Sunrise Senior Living — failed to ensure its workers were not working with virus symptoms. It also alleges that they failed to train, instruct and/or monitor the proper use of personal protective equipment. to prevent the spread of COVID-19.
On Thursday, The Star obtained the state report that found violations during an inspection earlier this month that put all residents who lived in the assisted living and memory care area in “immediate jeopardy related to the spread of COVID-19.”
The facility was issued an “Immediate Jeopardy” tag on May 11, which is the most severe citation, by the Kansas Department for Aging and Disability Services. But the administration and staff were able to address the issues immediately and the tag was removed during the onsite inspection.
The report found that an employee had worked last month even though the employee didn’t feel well and had positive signs or symptoms of COVID-19, putting residents in “immediate jeopardy” of infection.
The employee, a certified nurse aide, recorded having positive symptoms of COVID-19 on a screening form on April 16 and April 17 but was still allowed to care for residents in seven rooms that comprised the “Blueberry” unit, according to the report. The employee, along with three residents, then tested positive for COVID-19 on April 22.
“The deficient practice placed the residents of the ‘Blueberry’ unit in immediate jeopardy due to the increased risk for transmission of the potentially fatal COVID-19 Virus,” the report said.
And a May 13 report, based on complaint investigations conducted from May 6 to May 13, found that numerous employees had worked when they had symptoms of COVID-19.
In addition to failing to send staff home when they were sick, the report said, the administrator “further failed to ensure staff followed appropriate use and reuse of PPE in order to prevent the spread of COVID-19 throughout the assisted living and memory care areas of the facility.”
Staff and administrators at Brighton Gardens continue to follow guidance from the CDC and other health agencies, Falco said Friday.
“Officials at the Johnson County Department of Health and Environment confirmed again today that we are taking all necessary actions,” Falco said, “and have the appropriate precautions in place to prevent the spread of the virus. “
