February 1, 2024 - 9:20 pm
In October of last year, Leah Lau sent an official complaint to the Nevada Bureau of Health Care Quality and Compliance regarding the Nov. 10, 2022 death of her grandfather, Grant Lau, who had been a resident at the Southern Nevada State Veterans Home (SNSVH) in Boulder City.
Lau had been infected with Covid at the time of his death. The complaint noted that in the same two-week period of Lau’s death, two other residents of the home also died with Covid.
“It has come to my knowledge that the Infection Control Department at the veterans’ home was not testing their staff for Covid-19, AS WAS IN THEIR OWN WRITTEN POLICY,” the complaint reads (all caps are as written in the complaint).
The complaint continues, “The Infection Control staff, who monitored the testing of the staff (and residents) once or twice weekly (depending on county rates of infection), was well aware that staff was not being tested regularly. This is negligence and quite probably led to the three residents’ deaths.”
The complaint makes an accusation about former Director of the Nevada Department of Veterans Services Fred Wagar, reporting that the director, “said in a meeting that ‘we caused the death of the three residents by not testing our staff, per policy.’”
Lau’s complaint sums up asking the state to investigate her claim saying, “Since this occurred, there has been no transparency, instead being a cover-up by the leadership there of the tragic consequences of their appalling negligence.”
Following up on a tip about Lau’s complaint, the Boulder City Review filed an extensive request under the Nevada Public Records Act for any available documents referencing Covid-19 testing of employees at the Veterans Home. Note that a follow-up request for a head count of total employees per week during the second half of 2022 has not yet been fulfilled. According to NDVS Communications Director Terri Hendry, the request has been forwarded to the office of the Nevada attorney general.
The head-count request was the third document request made since the Review began interviewing current and former employees of the Nevada State Veterans Home in Boulder City in early 2023.
While the head-count numbers have not been provided yet, it is possible to look at reports generated by the Infection Control staff at the home and see that the number of employee tests being performed swung wildly over the period examined. And there are several instances of comments made in emails about employees — including the administrator then overseeing SNSVH — not complying with the testing requirements.
The BCR has been able to talk with two people who say they heard Wagar make the accusation blaming staff for the 2022 deaths. It reportedly came during a weekly leadership meeting held over Zoom on or around Dec. 1, 2022. Only one of those people would go on the record, then Director of Nursing Poppy Helgren. However, both attendees reported that Wagar said, “We killed three patients” and blamed the then-current Covid outbreak on lax employee testing.
On Dec. 27, when the documents from the second Nevada Public Records Act request were provided, Hendry included this note: “We can emphatically state that at no time was the resistance of mandatory Covid-19 testing by staff responsible for Covid-19 related deaths at the home. You will find a review of the documents supports our claim. We can find no information that supports your implied supposition that such a statement was made.
“Your sources were in leadership roles at the Southern Nevada State Veterans Home during the time frame of your request. They had the responsibility to ensure all Covid-19 policies, rules, and regulations were strictly followed. It was their duty and obligation to do so.”
Hendry went on to state, “Soon after his appointment to serve as director, Director Wagar realized some inconsistencies in following Covid-19 policies, rules, and regulations. He immediately stressed to leadership at the home that all Covid-19 regulations would be followed. Director Wagar is extremely pleased with the current leadership at the home and the compliance of the entire staff ensuring the safety of all staff and residents.”
Less than a month later, on Jan. 19 of this year, Director Wagar was reportedly dismissed. Despite multiple attempts to get comments about Wagar’s separation from NDVS via the office of Gov. Joe Lombardo, no information has been forthcoming about what Hendry referred to as a “change in leadership” in an email to staff. Another publication reported that the governor’s outgoing chief of staff said that it was a “personnel decision” with no explanation. The Reno Gazette-Journal has reported that the separation was a dismissal. Multiple emails to the governor’s press office have gone unanswered and unacknowledged as of press time.
There are multiple references to issues with testing including notes that the issue had been ongoing since 2020 and a reference to a comment from the then-administrator of SNSVH that he had not been testing twice weekly as required. On June 28, 2022, Corine Watson, a registered nurse who headed up Infection Control at the home and at one point had been named as the acting director of nursing sent an email to team leaders saying that some employees had stopped reporting for mandatory Covid-19 testing. At that point, Watson reported that — of the employees who were actually getting tested — there were no reported infections. But by July 15, 2022 another email from Watson reported that a volunteer at the home had tested positive and had since died due to Covid and that there were six staff members who tested positive.
It was not until December of 2022, after the outbreak that led to the deaths of Lau and two others and at about the same time that SNSVH was scheduled for an extensive federal inspection called a survey by the Centers for Medicare and Medicaid Services, that discussion appears in email records about the need to set up a written policy so that employees who skipped testing could be disciplined. Note that while there was written policy about the need for all employees to test twice each week, there was no written policy describing disciplinary actions that could be taken for those who did not comply with the testing policy.
The documents provided revealed more than just issues with testing. Note also that after inquiries about staff shortages for a story in April of 2023, Hendry and Wagar, in a phone call to the editor of the Review insisted, as did the current administrator of the home Steven Pavlow, that there was no staff shortage. They all referenced the fact that, in Nevada, there is no legally-mandated ratio of nurses to patients. Regardless, in a report to the state on July 20 of 2022, Watson noted the following: “SNSVH continues to have a staff shortage. There are 25 vacant CNA positions and five vacant RN positions.” This is one of several references in emails to staffing shortages. Indeed, there is extensive discussion of a proposed pilot program that would allow medical assistants to take on activities usually done by licensed nurses that was billed as a way to address staffing shortages.
According to calendars provided by current employees of SNSVH, for the entire months of November and December of 2022, the home took in no new patients, citing staffing issues for the hold.
In terms of employee testing, in December of 2020, more than 400 employee tests were reported in a single week. In December of 2022, only 281 tests were performed in the entire month. In some weeks during the second half of 2022, as few as 50 tests were reported to have been taken, according to documents.
Helgren was the director of nursing at SNSVH for the entire period of the Covid-19 pandemic, starting in 2014 until she retired in August of 2023 due to what she called “bullying and targeting” of her by Vivian Ruiz, who had been the deputy director of NDVS in charge of both of the state’s veterans’ homes during most of Wagar’s tenure. Ruiz left or was dismissed in August, about two weeks after Helgren retired. No information has been provided by NDVS about the reason Ruiz no longer works for NDVS. Her position remained open until it was filled by Mark McBride shortly before Wagar’s departure was announced.
McBride had been the administrator in charge of SNSVH in 2014 and left for a job with a private sector nursing home in Boulder City about a month before the family of a resident, Charles Demo, sued the veterans’ home and the state as well as naming McBride personally over the death. The suit alleged neglect and said that Demos had died as the result of an outbreak of Legionnaires’ Disease at SNSVH. The state eventually settled that suit for $750,000 after attempts to have that legal action dismissed were unsuccessful.
Speaking about the Covid-19 testing issues, Helgren said in an email, “When it was discovered that staff were not tested per the facility policy, resulting in an outbreak, there should have been an after-action review done to see what the hell was going on in the infection control department. Even with audits, Fred (Wagar) and Vivian (Ruiz) refused to do anything substantial, and they swept everything under the rug. They refused to look into [an employee’s alleged] time theft. They refused to allow me to write [the head of Infection Control] up for lack of supervision of her department. Fred, as the director, refused to do his duty as a reasonably prudent person, to investigate the allegations. He just covered everything up.”
Speaking about her grandfather, Lau said he had been a resident at SNSVH for about eight years. According to the death certificate she provided, he died as a result of pneumonia, which was the result of Covid infection. She added that her grandfather served in the Army from 1950-1953 and that she filed her complaint after overhearing staff at the home talking about Wagar reportedly blaming staff directly for several deaths, including that of her grandfather.
She reported that the family is actively seeking representation in order to file legal action against SNSVH and NDVS.
Contact reporter Bill Evans at email@example.com or at 702-586-9401.