Two former Kaweah Health nurses are facing possible loss of their licenses to practice in the wake of the negligent death of a patient under their care at the Kaweah Health Medical Center emergency department.
Gross Negligence, Incompetence & Unprofessional Conduct Alleged
Shelby Corwin and Jessica Pierce stand accused of gross negligence, incompetence and unprofessional conduct by the Office of the State Attorney General. The accusations stem from the death of patient Eric Burger Sr, who died in the Kaweah Health emergency department (ED) on October 1, 2023, while in the care of Corwin and Pierce.
A state investigation of Burger’s death found Corwin and Pierce ignored the patient’s obvious distress as he lay untreated or evaluated feet away from where the pair were seated. Burger died as a result of untreated cardiac arrest. State investigators placed responsibility for his death on Kaweah Health’s failure to properly supervise its ED operations and oversee its workers.
“The facility (Kaweah Health ED) failed to ensure … Patient 1 (Burger) was triaged upon arrival to the emergency department,” states the California Department of Public Health (CDPH) investigatory findings. Those findings were released on November 14, 2023. “This failure resulted in the delay of a medical screen exam for Patient 1 (Burger), who suffered a cardiac arrest.”
Burger died as a result, and ED staff were unable to revive him.
The Board of Registered Nursing (BRN), a department of the state Office of Consumer Affairs, is the complainant. An administrative law judge will oversee the women’s disciplinary hearings. An accusation from the BRN is the term used for a formal set of charges against a registered nurse who has allegedly violated the state’s Nursing Practice Act.
The accusatory complaint against Corwin was filed by the Attorney General’s Office on April 10. A virtually identical set of accusations was filed against Pierce on April 22. No hearing dates have been announced by the BRN, which does not provide a schedule of these matters to the public.
‘Extreme Departure from the Standard of Care’
According to the documents filed by the AG’s office, both Pierce and Corwin failed to provide care in the manner “ordinarily … exercised by a competent registered nurse.”
On the date of Burger’s death, Corwin, a charge nurse in the ED, was told of the patient’s imminent arrival via ambulance. Burger’s condition was described by the ambulance crew as urgent, requiring the highest level of response. Corwin argued about the patient’s condition with paramedics, and failed to properly prepare for his arrival, the BRN complaint states.
Burger’s implanted cardioverter defibrillator fired between the time of the radio report and Burger’s arrival at the ED. When informed, Corwin still did not perform a triage assessment of Burger, according to the BRN. Burger was eventually placed in a treatment room, however he had no pulse by the time this occurred.
Burger was pronounced dead at 5:42 p.m., 38 minutes after he arrived at the ED.
During the state’s investigation of the incident, which began the day following Burger’s death, Corwin told CDPH investigators she had not become concerned by the ambulance crew’s report of Burger’s condition and was not responsible for him until he was registered at Kaweah Health, despite being inside the ED at the time.
Corwin also claimed to have performed an “across the room” evaluation of Burger’s health while she remained seated several feet away. Corwin maintains she was not aware why Burger had been transported to Kaweah’s ED. She also failed to ask questions to find out.
Corwin was negligent, the BRN claims, for failing to get a report from the ambulance crew, inadequate assessment of the patient’s condition, failure to recognize Burger’s deteriorating state, failure to change her treatment plan when his condition worsened and failure to accept responsibility for his welfare once he arrived at Kaweah Health.
Seen as a whole, the BRN argues Corwin’s actions and failures to act constitute “an extreme departure from the standard of care which, under similar circumstances, would have ordinarily been exercised by a competent registered nurse. Such an extreme departure means the repeated failure to provide nursing care as required or failure to provide care or to exercise ordinary precaution in a single situation which the nurse knew, or should have known, could have jeopardized the client’s health or life.” In other words, gross incompetence.
Because of the events surrounding Burger’s death, the BRN accuses Corwin not only of gross negligence, but also incompetence and unprofessional conduct.
Pierce faces identical accusations for the same reasons. During Pierce’s “across the room” assessment of Burger, she decided he was “not a critical patient,” the BRN said. She also stated the ambulance crew’s request for urgent care did not concern her and so she made no preparation for Burger’s arrival.
Pierce, too, claimed Burger was not her patient until his registration was complete, and so had no responsibility to care for him.
Accused Nurses May Still Be Working in Valley Hospitals
The BRN has requested both Corwin and Pierce be stripped of their nursing licenses. Corwin is licensed to work in geriatric care, medical surgical environments, as an assistant instructor, and in psychiatric and mental health settings. Pierce is licensed for medical surgical work and as an assistant instructor. Both are licensed registered nurses. Neither has a record of previous action against them by the BRN.
The BRN has also requested the two be required to pay for the cost of investigating the case and enforcing it. They also seek any “further action as deemed necessary and proper.”
Yet until the hearing, both women are still licensed RNs. According to rumors circulating among Kaweah Health employees, the two women quickly found new nursing jobs after leaving their former positions in the wake of Burger’s death.
The two are now reportedly working at nearby local hospitals, one at Adventist Hanford and another at Community Regional Medical Center in Fresno.
According to Kaweah Health records provided by Transparent California, Corwin earned $90,758 in regular pay in 2022. Including overtime, undescribed other pay and benefits, she earned $120,963 that year. The same source lists Pierce’s 2022 base income as $81,998. With other pay and overtime, she grossed $128,122 that year.
Whistleblower Heartened to See Action in Burger’s Death
The results of the BRN investigation were not publicized by either the CDPH and Kaweah Health. Further, Kaweah Health officials are alleged to have lied about the events leading to Burger’s death to his surviving family. The family was informed by Kaweah Health that Burger died while en route to the ED, rather than while under the hospital’s care.
It was this lack of transparency and failure to take responsibility for their part in Burger’s death that drove former ED employee Kevin Barnes to make the issue public via social media. Kaweah had already fired Barnes by the time he made his disclosure. Kaweah Health executives accused Barnes of endangering patient safety by violating confidentiality, which he denies. In essence, Kaweah Health has publicly accused Barnes of a criminal violation of HIPPA, the federal law that protects patient information.
Still, he’s feeling much recovered from the stress he experienced from the fallout of Burger’s death at Kaweah Health. Burger was an ED employee who oversaw records.
“I’m doing a lot better with all the recent updates in the last two months,” he said. “I feel like things are starting to work themselves out the way they should be.”
Now that the state is challenging Corwin and Pierce’s licenses, he has a sense he accomplished something important.
“If that’s the bare minimum that happens, that’s good. They don’t deserve to practice medicine,” Barnes said. “For a while I felt like I was the only one who was going to lose his job. For a long time it seemed like that was how it was going to be.”
More Consequences and Compensation Would Be More Satisfying
Barnes would like to see his former employer and any individuals found at fault to be held fully accountable for the inadequate treatment of Burger and the lasting fallout from the October 1, 2023 incident.
“These nurses should be held accountable. The Hospital should be held accountable,: he said. “I feel like things are going in that direction. The family’s case is going forward.”
But Barnes also says the lying and dodging of responsibility is part of the culture at Kaweah Health. The district’s image, he said, is more important to the people running the district than caring for patients.
Barnes is a bit jaded following his experience.
“I felt like I was really naive. When this all happened, I felt like I was the only one surprised that this happened, that they let a patient die, that they didn’t tell the family. It seemed like it was a regular thing going on,” Barnes said. “When I said to my former coworkers they lied to the family, they said of course they lied to the family. Why wouldn’t they lie to the family?”
He didn’t always feel this way.
“I used to be really proud to work there,” Barns said. Then seeing the daily reality of working for Kaweah Health finally became too personal — he grew up with Burger’s children — and too much to take. It still haunts him.
But he still believes through it all, “I know there are a lot of good things going on there.”