Report blisters Southern California firefighters for failing to enter acute care center to treat dying patient

Three Rialto firefighters failed to provide “reasonable and professional care” and ignored pleas for help by nurses when they refused to enter an acute care center and treat a man in full cardiac arrest because of coronavirus protocols, according to a report released by the city.

Capt. Josh Gilliam would not allow any member of his fire crew to enter Rialto Post Acute Care Center after they responded to a 911 call about 8 p.m. on Nov. 17, 2021, according to the independent report, which was released by the city in response to a public records request from the Southern California News Group.

The patient, Joseph Angulo, later died at a hospital.

Firefighter-paramedic Matt Payne, according to the report, inappropriately told staff at the facility they would not enter the premises to medically treat or transport Angulo, instead requiring nurses to bring the patient outside. And fire engineer Mark Brady failed to appropriately handle a dispatch regarding Angulo, according to the report’s findings.

Gilliam and Payne were subsequently fired. Brady was suspended but has since returned to work. All three are contesting their discipline via a pending arbitration process, according to sources close to the case who asked to not be identified.

The city report emphasized that “there can be no delay or unnecessary distractions in providing patient care and transport.”

“The fire personnel charged with that responsibility in this instance failed to provide reasonable and professional patient care — or even adequate customer service — to the patient and facility staff,” the report states. “Whether this was because they were frustrated with having to handle so many calls there previously, or whether they were just having a bad day, it was inappropriate and inexcusable.”

The city commissioned Laguna Niguel-based JL Group, LLC to conduct the personnel investigation, which was led by Jeffry Johnson.

Following policy

The firefighters maintain they were strictly adhering to Rialto Fire Department COVID-19 protocol on the night of the incident. The department policy, dated Aug. 13, 2020, directed firefighters, when responding to calls at licensed medical facilities, to “attempt to get the staff to move the patient to open area via wheelchair or mobile bed, if able do not bring the gurney into the facility.”

Fire Chief Brian Park said in an email Friday that local or state emergency medical service providers, including Rialto’s, were never prohibited from entering skilled nursing facilities to provide care, especially for high-acuity patients or facilities needing assistance.

By November 2021, due to widespread vaccination and improved knowledge, many COVID-related mandates had been lifted. For example, family visitation at nursing homes was expanded, family members were permitted to ride in ambulances with patients, and mask mandates had been rescinded or minimized — all prior to the omicron variant, Park said.

Park said the August 2020 policy also directed all fire department personnel to wear personal protective equipment (PPE) prior to entry into a licensed medical facility.

“The goal was to reduce cross-contamination during the extremely high percentage of low-acuity incidents; the goal was not to prevent personnel from entering to assist in high-acuity situations or when requested for aid,” Park said. “This direction was reinforced in departmental training, briefings, emails, and meetings. There was a continuous emphasis to take care of our patients, our community, and each other.”

Uniform guidelines

According to the report, the Riverside County Fire Chiefs Association put together a task force at the beginning of the pandemic and visited skilled nursing homes to assess their needs and help them determine what would be a reasonable and prudent response for firefighter-paramedics. It was agreed that, to limit exposure to the coronavirus, only one paramedic should enter such facilities and assess the situation before sending in other personnel.

The Rialto Fire Department adopted those guidelines, and provided them to all department personnel, along with its own drafted coronavirus protocol, according to the report.

“No policy or guidelines, either state or local, ever prohibited fire personnel from entering a skilled nursing facility to treat a patient due to Covid,” the report stated.

Attorneys at the law firm Mastagni Holstedt, representing the three firefighers, did not respond to a request for comment.

Body camera footage

While Gilliam, Payne and Brady did not enter the acute care center that evening, Rialto police Cpl. Ralph Ballew did. His body camera footage, provided by the Rialto Police Department, shows the officer passing Gilliam and Payne, standing at each side of the entrance, to enter the facility.

A frantic staff member tells Ballew, “It’s cardiac arrest!” Ballew, looking around, asks, “Where is he?” Another staff member, spotting the officer, waves him toward Angulo’s room, saying, “Come quick!” and “What the hell?”

“They are not coming in. They’re saying it’s a state law — that they can’t come in,” Ballew tells the staff nurse, referring to the firefighters. The nurse told Ballew they could not move Angulo while they were doing chest compressions.

But move Angulo they did. Ballew assisted several staff members in pushing Angulo’s bed out his room, down the hallway and to the exit, while a staff member sat atop Angulo on the bed performing chest compressions.

From the time Ballew entered the facility to the time Angulo was pushed outside, two minutes passed. When they got outside, Gilliam immediately asked how long Angulo had “been down.” Ballew then said, “Someone needs to communicate with the fire department!” A staff member responded, “Probably about 25 minutes.”

Gilliam then asked a staff member how long they had been doing chest compressions on Angulo, to which the staff member replied, “Uh, about 10 minutes.”

Angulo was taken by ambulance to Arrowhead Regional Medical Center in nearby Colton, where he died.

In his report, Ballew, now a sergeant, noted that one of the firefighters told nursing staff, “You are doing the same thing we would have to do if we went in, so hurry up and bring him out so we can help.’ He also noted that one of the paramedics told him that if the nursing staff did not appreciate what they were doing, “they should call their congressman.”

“Had the firefighters responded reasonably, they would have become aware that, among other issues, that fire dispatch was actively instructing staff at the acute care facility to perform CPR on Angulo and wait for the paramedics to come to them, as was standard practice and reasonable,” according to the report.

“The three subjects of the investigation clearly sought to minimize the level of concern and even panic expressed by the nursing facility staff by this incident. It appears extremely unlikely that Gilliam, Payne and even Brady did not hear any of the staffs’ pleas for help or sense their panic and concern.”

Daughter suing

Angulo’s daughter, Bridgette Angulo, has sued the city. She filed a $100 million claim, a precursor to a lawsuit, against Rialto in March, then a wrongful death lawsuit in August.