Lytton Gardens reprimanded over care of patients | November 16, 2012 | Palo Alto Weekly | Palo Alto Online |

Palo Alto Weekly

News - November 16, 2012

Lytton Gardens reprimanded over care of patients

State health officials call for correction after facility fails to provide prompt assistance

by Sue Dremann

The California Department of Health and Human Services is requiring Lytton Gardens Skilled Nursing Facility in downtown Palo Alto to retrain and monitor its staff after an investigation found staff took as long as one hour to respond when a resident asked for help getting to the bathroom.

The long wait violates a state requirement regarding "the dignity and respect of individuality," an Oct. 31 report stated.

Investigators, acting on a patient's complaint, went to the 145-bed facility on Webster Street on Aug. 13 and found it failed to ensure that the call light, which patients press when they need help, was answered promptly.

Lytton Gardens officials have now filed a corrective plan with the state and promise to closely monitor staff, who have been instructed to respond quickly to calls.

Although the state was acting on a single complaint, some Lytton Gardens patients and their families have told the Weekly that staff frequently ignored call buttons. Some people said they either experienced or saw patients who were left in their own waste for hours, leaving them in discomfort and feeling ashamed.

The issue investigated by the state first came to the Weekly's attention in late August. A patient was admitted to the skilled-nursing facility in July with difficulty walking, muscle weakness and a history of stroke. She was lucid, not cognitively impaired, and was able to readily communicate, according to a state report.

The patient told the investigator that on her first night at Lytton Gardens she waited for 10 to 15 minutes before anyone answered her call light, and she was in some discomfort. The investigator, based on her observations, interviews and record review, concluded that patients were waiting up to an hour for help, according to the report.

A certified nursing assistant also allegedly told the patient to yell for help if the call light was not answered right away. The facility's director of nursing told the investigator she had looked into the complaint the next day, but she could not substantiate it because the patient was not able to identify the nursing assistant. She counseled the nursing assistant who was in charge of the patient that evening, she said.

During an inspection at 4 p.m. on Aug. 16, the investigator observed call lights were being answered in "a reasonable time" of one to five minutes. A 2003 facility policy about call lights directs nurses and assistants to "answer the resident's call as soon as possible," the investigator stated.

The investigation only pertained to the single complaint, and the entire facility was not reviewed, the report noted.

But other residents and family members of patients said the problem was more pervasive.

Liseli Walan said her mother had to wait more than an hour after pressing the call button. Walan said during visits to her mother she observed multiple call lights that were activated outside of rooms and stayed on for 20 to 30 minutes. At one point she became so fed up with seeing the calls unanswered that she went into a room to help a patient get her dentures to the sink, she said.

Her mother became so frustrated with waiting to be helped from her wheelchair to her bed that she tried to move herself and risked a fall, Walan said.

On one occasion, Walan said she saw a patient with Parkinson's disease slip down in her wheelchair onto the floor. Walan said she pressed a call button, but no one came. The patient was finally helped after a 12-year-old boy visiting a relative sought out an assistant to help get the woman back into the chair, she said.

Walan's mother is no longer at Lytton, she said.

"You're in a compassionate position," she said, referring to Lytton Gardens staff. "This is people you're dealing with; this is not data entry."

The daughter of one resident, who spoke under the condition of anonymity, said earlier this week that her mother's roommate was left sitting on her bed pan and was hollering for help. The roommate waited for a long time until her pleas were finally addressed, "Maryann" said.

The nursing assistant insisted to Maryann that the roommate had already been removed from the bedpan.

"You're not on your bedpan — oh, I guess you are," the nursing assistant finally said after coming in to see the patient, according to Maryann.

"People are sitting in their own dirty diapers. People are turning their lights on, and nobody is answering them," Maryann said.

Staff also used harsh paper towels to clean the patients and did not put ointment on their bottoms, she said. Patients who were able to get to the bathroom on time were brought out of the toilet and put to bed without washing their hands or being given hand sanitizer, she said she observed. She added that she plans to file a complaint with the state.

One patient spoke to the Weekly by phone in late August while at the facility.

"Iris" had contracted an intestinal infection and was in a diaper due to persistent diarrhea, she said. She frequently employed the call button, but she was sometimes left for two to three hours without a diaper change, she said.

"You dare not bother them during their dinner hour or from 7 to 10 p.m. during the Olympics," she said. "The assistants would say, 'Your nurse is busy now.'"

She said the staff was always pleasant, but she would press the call button and a young nursing assistant would come in and turn it off. The assistants would say they told her attendant to come in, but she would have to press the button again and again.

"It shouldn't be a disgrace, but it is, to be left in your waste," she said.

"The poor nurses are harried and flustered. They are begging you to wait and they will be in soon. The nurses say, 'I'm so sorry. I have eight patients today.' They are doing their best," she said.

But Ivy Adjivon, senior director of health services, said Lytton Gardens has a nursing assistant-to-patient ratio that is better than the state requirement. The state requires each staff member to supply 3.2 hours of care per patient per day. Lytton Gardens provides 3.8 hours of staff care per patient per day, she said.

Lytton Gardens submitted its corrective-action plan to the state on Oct. 29, which was accepted. In it, administrators acknowledged that although the patient mentioned in the complaint no longer lives at Lytton Gardens, "all residents have the potential to be affected by the same practice."

The director of nursing services held meetings with nursing assistants and nurses regarding call-light compliance on Oct. 26, 28 and 29. Department directors were to be re-educated about the call-light policy on Oct. 31. Daily rounds will be conducted to monitor staff response time to answering the lights by the director of staff development. And nursing supervisors will remind nursing assistants and staff at the start of shifts about the policy of answering the lights.

A call-light study will be conducted monthly by the director of nursing service to ensure policy is being followed, and department directors will interview patients to make sure they are comfortable with the call-light responses, among other monitoring procedures.

Dee Ann Campbell, senior vice president of Episcopal Senior Communities, the parent company of Lytton Gardens, said the company takes complaints seriously and works to correct the problems. A plan of correction is an important piece of remedying a problem, but communication is also important on a regular basis, she said.

The correction plan "is not a one-time reminder," she said.

Ralph Montano, a spokesman for the California Department of Public Health, said nursing homes are inspected about every nine to 15 months, but investigators go in more frequently when there are complaints. Some complaints are deemed unsubstantiated, but that doesn't mean the violation didn't occur, just that at the time of inspection, no proof could be found, he said.

He said it is important to file complaints with the department whenever someone sees something occurring that is concerning. Complaints have been filed by residents, nurses and patients' families. The department's ombudsman can be called toll-free at 800-554-0353. All reports are anonymous, he said.

"We conduct thousands of on-site inspections each year. These are the kinds of complaints we are here to respond to," he said.

Since the Affordable Care Act, the state now posts complaint information about each facility on its website at Click on "health information" and "health facility consumer information."


Numerous senior-living facilities in the area — including Palo Alto, Mountain View, Menlo Park and Portola Valley — have been investigated by the state Department of Public Health this year. Read a summary of the violations on Palo Alto Online.

Staff Writer Sue Dremann can be emailed at


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