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"Escondido nursing home gets most serious citation" by The Union–Tribune

By J. Harry Jones
6:56 p.m. February 20, 2008

ESCONDIDO – A nursing home in Escondido has been issued the most serious citation the state can impose, for the second time in two years, following the death of a 94-year-old woman on Thanksgiving.

Maria Cobian, who had a history of wandering off and wore an ankle bracelet that sounded an alarm, somehow left the Palomar Heights Care Center on Ohio Street. She was struck and killed by a car on nearby Grand Avenue in the middle of the night.

According to a citation issued recently by the California Department of Public Health, “the facility staff failed to provide adequate supervision and interventions to prevent one confused resident from eloping from the facility, undetected by the facility staff, which resulted in the death of the resident after she was struck by an automobile.”

The report also notes that a nurse told police during an investigation that Cobian was checked and found to be sleeping in her bed at 12:45 a.m. – twelve minutes after she had been killed.

“Staff members were unable to provide an immediate reason for the discrepancy,” the report says.

The citation, called an AA, is the most severe the state can issue and carries a $100,000 fine, said health department spokesman Ken August. Fewer than two dozen AA citations are issued statewide each year, August said.

A facility that gets three AA citations within one year can have its license revoked, he said.

Palomar Heights issued a statement Wednesday night: “We have responded to the citation as required. Our staff is deeply saddened by this unfortunate incident and have taken all steps necessary to ensure our resident's ongoing safety.”

In February 2006, an AA citation was issued to Palomar Heights after a 66-year-old man burned to death. The man was left alone while smoking a cigarette on a patio while connected to an oxygen machine, a report of that accident said, when he became “engulfed” in flames and burned for six minutes.

The report of Cobian's death says he had been a patient at the home for slightly more than a year. She suffered from senile dementia and had a history of wandering and trying to leave the facility.

The night of her death, she was agitated and began wandering around the home, according to the report. At least twice, staff members intervened when alarms were activated by a Wanderguard bracelet attached to her leg.

Nursing home documents indicate that from 8 p.m. until 11:45 p.m. Cobian was checked every 15 minutes. A note recorded at 11:40 p.m. said she had been medicated and that the staff would “continue to monitor.”

The last note, at 1 a.m. Nov. 22, said Cobian was missing. Two weeks later, a nursing supervisor “confirmed that the nursing note was incomplete and unsigned,” according to the health department report.

August said Palomar Heights is appealing the citation, which was issued three weeks ago.

Cobian came to the United States 45 years ago and spent decades living in Carlsbad and working in the flower fields there, her grandson, Jesus Cobian, said in an interview last November. She walked all over the city for years, he said.

“She was a go-getter. If there was something she wanted she'd get it,” the grandson said.

Jesus Cobian could not be reached for comment Wednesday.

Mike Connors, a spokesman for an advocacy group called California Advocates for Nursing Home Reform, said Palomar Heights' recent history of citations is disturbing.

“For one institution to be issued two (AA citations) in two years is very telling,” he said.