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"State issues top fine, citation to
Palm Desert nursing home in woman’s death"

The Press–Enterprise

The Press–Enterprise
10:00 PM PDT on Tuesday, April 22, 2008

A Palm Desert nursing home faces a $100,000 state fine and AA citation after a patient died of infection caused by a perforated colon.

The fine and citation are the most severe that investigators with the California Department of Public Health could issue to a nursing home.

The agency released its report on The Springs at the Carlotta on Tuesday. It was the first AA citation and fine disclosed about a Riverside County nursing home this year.

Lea Brooks, spokeswoman for the state Public Health Department, said nursing home officials were notified of citation and fine March 21. They appealed April 8.

Paul Sibel, administrator at The Springs at the Carlotta, didn't comment Tuesday.

The Springs at the Carlotta, a 59–bed facility at 41–505 Carlotta Drive, was cited some time around March 21 for failing to identify and monitor the medical needs of an 87–year–old woman, who suffered from constipation for 24 days, according to the citation.

The woman died of acute peritonitis, a perforated colon and severe constipation, the citation states.

The woman, who was not identified, was admitted to the home June 5, 2006, to recover from a broken pelvis. Administrators knew the woman was constipated when she arrived at the nursing home, the citation states. The facility staff failed to properly document the woman's treatment for constipation and steps taken to help her.

The woman became so ill that she began vomiting June 22, 2006, according to the citation. She died seven days later after she was taken to a hospital for diagnostic tests. Medical workers had just completed a CT scan of the woman when she died, the citation states.

Inspectors went to the nursing home Sept. 27, 2006 –– three months after the woman's death –– to investigate a complaint, according to the citation. Brooks said inspectors received the complaint Sept. 6, 2006.

It took investigators almost a year and a half to finish the investigation because of extensive internal review, she said. They also had to wait a year before they got a report on the woman's death from the Riverside County sheriff–coroner's office, Brooks said.

Pat McGinnis, executive director of California Advocates for Nursing Home Reform, said she was appalled by the woman's death and the state's slow investigation of it.

"Imagine if you're a relative of one of these people," she said. "No wonder people lose faith in the system. This is terrible."

The Springs at the Carlotta hasn't been issued a fine or citation since 2001, according to records. Medicare and Medicaid's nursing home Web site, called Nursing Home Compare, shows state regulators found 11 health deficiencies when it was last inspected in April 2007."

Nationwide, nursing homes average eight deficiencies per inspection, according to the Web site. California nursing homes average 13 per inspection.

The nursing home may appeal its citation to a review conference or an administrative law judge or file a lawsuit in Riverside County Superior Court. Another option is to pay 65 percent of the assessed penalty in lieu of contesting the citation.