January 10, 2019 02:45 PM

As outrage spreads over the revelation that a 29-year-old woman who’d been in a vegetative state for more than a decade unexpectedly gave birth last month at an Arizona nursing facility, it’s been twinned with a parallel — and unanswered — question.

How could no one there have known or reported that she was pregnant?

“It’s a little hard to believe that at times when she’s bathed or toileted that somebody didn’t see something,” Arthur L. Caplan, the director of medical ethics at NYU School of Medicine, tells PEOPLE.

Initial reports said staff members at the Phoenix long-term care facility operated by Hacienda HealthCare were unaware of the woman’s condition until she went into labor and delivered the baby boy on Dec. 29.

Police, who confirmed their sexual assault investigation in the case, said they found the woman “helpless” after officers responded to a call of a newborn in “distress” with trouble breathing, Phoenix Police Sgt. Tommy Thompson said at a news conference Wednesday.

In a follow-up interview with PEOPLE, Thompson says: “It’s my impression that the staff there had no clue that this lady was having a baby,” and that when she went into labor, “I think it took everyone by surprise.”

Hacienda HealthCare facility in Phoenix
Ross D Franklin/AP/REX/Shutterstock

The woman and infant are recovering at an area hospital, according to police, as the investigation broadens into what a member of the Hacienda board of directors described in a statement as “this absolutely horrifying situation.”

The company’s CEO has resigned.

Several factors might have led to the woman’s condition being overlooked, says Dr. Mark Ashley, the CEO and founder of the California-based Centre for Neuro Skills who sits on the board of the Brain Injury Association of America.

Neither Caplan nor Ashley are involved in the current case or affiliated with Hacienda HealthCare.

The Native America woman identified as a member of the Apache tribe suffered her brain injury in a near-drowning more than a decade ago, according to Phoenix-based news outlet KPHO-TV.

While care of such patients in residential settings is overseen by trained nurses, “the nursing staff probably was not involved in her personal care — the showering, the toileting, the dressing, the undressing,” says Ashley. “That would have largely fallen to aides.”

The lower ranks of certified nursing assistants receive less-sophisticated training, smaller paychecks, and see typically higher turnover, he says. “If a staff member sees her in the first trimester, and a second staff member sees her in the second trimester … you can imagine they’re seeing her for a short time and not recognizing changes” in a patient’s body, he says.

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“The staff would have known if she was menstruating,” he adds. But in the case of brain injury patients, “the complication is that the menstrual cycle may not have been regular. A patient may have just a few periods within a year, or may menstruate regularly, or anything in between.” Thus, an interrupted cycle may not have stood out.

“You have all of these factors that, in the worst of all situations, could combine to a legitimate miss, if you will,” he says.

Police and Hacienda HealthCare have confirmed the collection of DNA from male staffers in an effort to find a link to the apparent assault.

But “they’re also going to want to test visitors, which raises other thorny issues if someone who was a family member or a friend was involved,” says Caplan.

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Caplan concedes that staff members might have suspected the patient’s emerging pregnancy, but neglected to report it. “We’ll have to see what the testimony is from her caregivers,” he says.

Incidents of sexual assault of disabled persons leading to births are “not unprecedented,” says Caplan, although he could not cite statistics. “The institution has a responsibility to make sure the environment is safe for the residents,” he says.

In 2017, the same Hacienda facility was cited by the state for failing to protect residents’ privacy while they were naked in the shower, according to records from the state Department of Health and Human Services. After being assured by administrators that staffers “have been counseled on privacy during showering residents,” the state issued a follow-up report in January 2018 that concluded the deficiencies had “been corrected.”

Says Ashley: “This was preventable, there’s no doubt about it, and it’s obvious this patient was taken advantage of and it’s a disappointment without a doubt that better measures were not in place to make this much less likely, if not impossible.”

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