PHOENIX -- The revelation that a Phoenix woman in a vegetative state recently gave birth has prompted the CEO of a private health care facility to resign, putting a spotlight on the safety of long-term care settings for patients who are severely disabled or incapacitated.
Hacienda HealthCare CEO Bill Timmons stepped down Monday, spokesman David Leibowitz said. The decision was unanimously accepted by the provider's board of directors.
Local news website Azfamily.com first reported the woman, who had been in a vegetative state for more than 10 years after a near-drowning, delivered a baby on Dec. 29. Her identity has not been reported, and it's not known if she has a family or a guardian. It's also unclear if staff members at the Hacienda de Los Angeles facility were unaware of the pregnancy until the birth.
In a statement, board member Gary Orman said the facility "will accept nothing less than a full accounting of this absolutely horrifying situation."
"We will do everything in our power to ensure the safety of every single one of our patients and our employees," Orman said.
The birth has triggered a police investigation and reviews by state agencies. Gov. Doug Ducey's office has called the situation "deeply troubling."
"It makes me feel angry. It makes me feel like they failed her," a former Hacienda caregiver told the local ABC affiliate.
The former caregiver, who did not want to be identified, was dumbfounded as to how current staff and medical professionals could miss the obvious signs of a pregnancy.
"I can't believe it at all. I can't believe that somebody would bathe her daily for nine months and never know that she wasn't having a period, that she wasn't growing in her midsection, that nurses weren't keeping track of weights," the former caregiver said. "Those things are shocking to me."
Staff were supposed to be checking patients' beds every 15 minutes, though the former caregiver said some staff would "get lazy about doing them" at night during their tenure at Hacienda. The former employee also called out the facility for lax security measures.
"Too many entrances, too many opportunities. Anybody could've come in," the former employee said of the facilities unlocked doors. "I myself have come in the back way."
Phoenix police say the matter is under investigation and declined further comment Tuesday.
The Hacienda facility serves infants, children and young adults who are "medically fragile" or have developmental disabilities, according to the website. In the wake of the reports, the Arizona Department of Health Services said new safety measures have been implemented. They include increased staff presence during any patient interaction, more monitoring of patient care areas and additional security measures involving visitors.
The state's online complaint database for care facilities shows multiple complaints about Hacienda de Los Angeles going back to 2013. Most of them involve fire drill and evacuation preparation or Medicaid eligibility. But one complaint from December 2013 outlines an allegation that a staff member made inappropriate sexual comments about four patients two months earlier. Nobody relayed the incidents to an administrator. That employee was later fired.
Martin Solomon, a personal injury attorney in Phoenix whose clients are mostly vulnerable adult victims of abuse and neglect, said a lawyer representing this woman should call for all pertinent medical records, a list of current and ex-employees and any past litigation involving Hacienda. It would be the police who would lead DNA testing to figure out who fathered the baby, Solomon said.
It would be hard for Hacienda to escape any kind of liability in court.
"There's a lot of information we do not have, But things like this don't happen without someone either knowing about it or should have known about it," Solomon said. "Whether it's an employee or someone from the outside, the facility has an obligation to protect residents."
Advocates for the disabled say Arizona needs to find a way to monitor allegations of sexual abuse and sexual violence in these group settings. Doing background checks isn't enough, said Erica McFadden, executive director of the Arizona Developmental Disabilities Planning Council.
"I think when you've had somebody who's had multiple allegations from different parties, there has to be some way to track that," McFadden said. "If it's the same story from different people, then there's something wrong."
The council recently formed a task force to look at how to improve training for health care workers when it comes to identifying and reporting sexual abuse.
"We don't have a systematic way to train people what's a good touch or a bad touch. We also don't have required training for providers," McFadden said. "We really need a lot of work in this area."
Jon Meyers, executive director of The Arc of Arizona, an advocacy group for people with intellectual and developmental disabilities, called the allegations "disturbing, to put it mildly."
"I wasn't there. I clearly don't have firsthand knowledge of what happened," Meyers said. "But I can't believe someone receiving that level of constant care wasn't recognized as being pregnant prior to the time she delivered."
The woman and her baby are now being cared for in local hospitals.
WLS-TV contributed to this report.
Facility's CEO resigns after vegetative patient gives birth; former caregiver speaks out