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Maggots found under bandage at facility where incapacitated woman sexually assaulted, impregnated

Hacienda HealthCare

PHOENIX — Who is in charge at Hacienda HealthCare? It’s the question on many people’s minds with the health care facility back in the spotlight after a new disturbing incident involving a patient.

A report that several maggots were found around the surgical incision of a 28-year-old male resident has sparked a new investigation and swift action by the Arizona Department of Health Services. On Friday, June 13, the department issued an “intent to revoke” Hacienda’s state license that was recently issued to the facility.

The incident also has several Arizona lawmakers demanding answers and accountability. Hacienda is the same facility where a 29-year-old incapacitated woman was sexually assaulted last year. Police arrested and charged Nathan Sutherland, a 36-year-old nurse, from the facility alleging he raped and impregnated the woman.

As Hacienda was making changes and trying to rebuild trust within the community, the new investigation has several lawmakers concerned and outraged.

Senator Heather Carter co-sponsored Senate Bill 1211. The bill gives the state direct authority to go in and take action themselves, instead of just being an agent of the federal government.

Carter said she was “floored” when she heard about the incident involving the maggots.

“Absolutely floored. I have no words. It is unacceptable. We have to do something, and that is what we’re doing,” said Carter.

Carter also questioned who is really “calling the shots” at the facility.

“The oversight for this facility, in terms of day to day operations — yes, you have the staff — but ultimately, the Board of Directors oversees it. All roads in both these cases lead straight to the board. All roads lead to the board,” said Carter.

Carter echoed a statement made by Governor Doug Ducey in February, referring to the incident at Hacienda. In an interview with KTAR, Ducey said the system meant to protect vulnerable members in our community was not working.

“It’s inherently broken, and that’s why I want to fire the senior management and remove the board. I think we’ve got good, hard-working employees in there that want to do the right thing, but this has just been terrible leadership, terrible management, and terrible oversight” said Ducey.

Since those strong words from the Governor, ABC15 reported on several resignations and job terminations from Hacienda — from then-CEO Bill Timmons, to chief operating officers, department directors, and several members of the nonprofit organization’s board of directors. Some of them said they were stepping down because they felt “ineffective” as a board.

In an interview with ABC15, former board member Dr. Kevin Berger said he hoped other board members would follow suit and step down as well.

“Especially now, with all the resignations, I think there is no other choice but to have everybody resign, to re-structure, and to start again. We have to hit a reset,” said Berger.

A spokesman for Hacienda confirmed three original board members remained at Hacienda.

Senator Carter questioned why they were still there and why so many other seats remained empty months after the resignations of other board members.

“I think there’s a tremendous concern with the board. The same board that was in place when the horrific rape of a vulnerable patient occurred is still in place now, when we have this second horrific situation. Something has got to be done,” said Carter. “Right now, there are so many vacancies on the board, I don’t understand why they’re not moving swiftly to fill those vacancies,” she added.

Arizona Senator Victoria Steele from Tucson said she does not believe patients at Hacienda are safe.

“This is inexcusable. This is dangerous, and we have to do something. It is our responsibility at the state level to do something,” said Steele.

Governor Doug Ducey’s office issued a statement Friday, saying in part: “The care and safety of patients is a top priority. Our state agencies, including the Department of Health Services, the Department of Economic Security, and AHCCCS, are on-site to investigate. We are getting all the facts on this deeply disturbing allegation and we will take appropriate action to ensure accountability and the highest level of care for patients.”

ABC15 reached out to Hacienda officials to get answers on the vacant board positions, and to request interviews with current board members who remain. All requests were denied. A spokesman said, “I will let you know if my client chooses to offer answers.”

Carter said at the end of the day, no matter what happened at Hacienda, all responsibility for patient safety lies with these three board members who are still in charge of overseeing the facility.

“Something has got to be done to add people to the board to make sure there is proper oversight of the day-to-day quality measures that need to be in place for the facility to be functioning,” said Carter.

She added that she would like to see patient safety advocates, family members with loved ones inside the facility, health care experts, and those with first-hand knowledge of patient care included in the new board to oversee Hacienda.

Many in the community asked why this facility remains open. State officials said the answer is complicated. Many of the patients housed there are some of the most vulnerable and “medically fragile” people in the community. Moving them would be very difficult because there are not many places that offer the kind of care that Hacienda is equipped to handle. However, they said patient safety would be their number one focus as they determined how to proceed in light of the new investigation.

Carter told ABC15 that if there were any families who wished to remove their loved one from Hacienda, the state would provide the necessary support to make it happen.

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