At a Kansas City, Kan., nursing home, employees tested positive for the coronavirus and went back to work the next day.
Health workers cared for residents who had tested negative for the virus in the same gowns and masks they had worn into the rooms of those who had tested positive.
"I wash my hands," a nurse told inspectors. "But I wear the same PPE."
Now the federal inspection that documented those and other risky practices could play into 12 lawsuits brought by families against Riverbend Post-Acute Rehabilitation over the deaths of residents at the nursing home.
Dozens died of the coronavirus at Riverbend — one of the state’s deadliest nursing home outbreaks, a federal database shows.
"This report just confirms the allegations we’ve already made," said Rachel Stahle, a lawyer representing families in seven of the lawsuits. "It certainly bolsters our position."
What the Centers for Medicare and Medicaid Services found at Riverbend, she said, makes clear the home wasn’t taking proper steps to control infections.
"The report is not surprising," Stahle said. "Nonetheless, it’s still quite shocking. You have numerous employees who (were) working with symptoms."
Riverbend argued a federal law shields it against the lawsuits, but a federal judge rejected the argument two weeks ago. That cleared the way for the families to proceed in state court in Wyandotte County.
Stahle expects discovery — an evidence-gathering stage — will start within a month.
Riverbend didn’t respond to a request for comment on what appears in the inspection report.
After scouring Riverbend’s daily logs and interviewing its staff, inspectors concluded the home didn’t take vital steps to protect residents. That made it likely they would be exposed to the coronavirus, "resulting in serious harm or death."
The inspections took place in late April and early May, when the home had about 90 residents. Inspectors found employees weren’t following key guidelines to curb the virus’s spread — such as segregating residents who had tested positive for the virus from those who hadn’t.
Inspectors saw health workers caring for COVID-19 patients without proper protection. Some were missing gloves. Others lacked eye protection or a mask.
Residents were in "immediate jeopardy," the inspectors wrote.
That was after the virus made it into Riverbend sometime around late March and ravaged the place. Already, 32 deaths at the facility had been attributed to it. The home’s management figured the real toll was higher because not everyone who had died had been tested.
Tallies that Riverbend later reported to the federal government say 37 residents died of COVID-19, and more than 60 residents and 30 staff tested positive.
One nurse told inspectors she would wear a single mask for five days at a time. An aide said the building’s director of nursing told her she didn’t need one to work with coronavirus patients.
That aide ended up contracting the virus. Centers for Disease Control and Prevention guidelines say nursing home staff should don an N95 mask when caring for anyone suspected of having the virus.
The federal team also saw COVID-19 patients leaving their rooms and eating in the same common areas that residents who had tested negative were allowed to use.
The home’s managers told inspectors that 21 residents had still tested negative as of early April. But because a large number had tested positive, it was pointless to keep them apart or have staff don fresh protective gear between rooms. They assumed everyone was actually infected.
One resident who was clearly ill was kept with a roommate who seemed healthy. Both ultimately tested positive.
CMS and the CDC had already made clear by mid-March that nursing homes had to screen staff for a range of symptoms and tell anyone who was sick to quarantine at home.
Yet day after day, some employees walked into the building without anyone documenting their temperature or other symptoms. Others reported having coughs, shortness of breath or sore throats, then worked anyway.
A nurse and a medication aide both continued working in the days after they got tested and learned they were positive.
The lawsuits against Riverbend accuse it of negligence. They were filed in state court, but Riverbend argued a federal court needed to handle the matter because the Public Readiness and Emergency Preparedness Act shielded them against liability.
The PREP Act protects health care providers during health emergencies like the current pandemic against lawsuits over administering medications and other measures meant to combat a disease.
But Riverbend stands accused of failing to take measures, a federal judge found, so the PREP Act doesn’t apply and the cases will move forward in state court.