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"Nursing Home Gets State's Harshest Penalty
Care Inadequate For Man Who Died, Probe Finds"

Original source:

Stockton Record
By Joe Goldeen
Record Staff Writer
Nov. 14, 2009

STOCKTON - Valley Gardens Health Care and Rehabilitation Center, a 120-bed nursing home in north Stockton, has received a "AA" citation - the state's most severe penalty - and a $90,000 fine after an investigation concluded that inadequate care led to the 2007 death of retired Stockton businessman Robert E. Doscher.

Valley Gardens failed to ensure that the 92-year-old Doscher was adequately supervised and, as a result, he fell and later died, according to Dr. Mark Horton, director of the California Department of Public Health. By its own assessment, Valley Gardens knew that Doscher was a serious risk to himself but it failed to act properly in protecting him from falling, according to the state's recently concluded investigation.

Current Valley Gardens administrator Barbara Hutchison said this week that Doscher's care was supervised "under a prior administrative team, and we have filed a plan of correction with the state, and it has been accepted."

Hutchison added, "Of course, our goal is to keep our patients safe, and we take seriously any findings found by the state. Our thoughts are with the family."

She also said that to her knowledge, neither Valley Gardens nor its parent company plan to appeal the state's ruling.

Valley Gardens, 1517 E. Knickerbocker Drive, is a for-profit skilled nursing facility owned by Kindred Healthcare Inc. of Louisville, Ky. Kindred, with revenue of more than $4 billion as of June 30, operates 222 skilled-nursing facilities and more than 650 health care programs in 41 states, according to its Web site. Its Stockton facility has a two-star "below average" rating - out of five stars - on Medicare's Nursing Home Compare Web site, which looks at health inspections, nurse staffing and quality measures and then assigns ratings based on nationwide standards.

According to the state Department of Public Health's report, Doscher was admitted to Valley Gardens on May 18, 2007, from an acute-care hospital with a diagnosis that included a mini-stroke, coronary artery disease, irregular heart rhythm, artificial heart pacemaker, previous surgery for prostate cancer, a recent urinary tract infection requiring antibiotic therapy and a ground-level fall at home.

He required the use of a walker when he was admitted, and it was initially planned that he could be discharged to a board-and-care facility when his condition stabilized. He was assessed by Valley Gardens nursing staff as a "high risk for falls" and his chart indicated that he should be checked every one to two hours.

Also, he was to be told not to get up without assistance; a motion-monitor alarm was to be used to alert staff to any unsafe activity; and he should have been placed in front of a nursing station for closer observation.

Three days after he was admitted, he was found on the floor, where he hit his head, apparently after falling while trying to get back into bed by himself, according to the state's report.

As of June 4, the report notes that "there was no documented evidence the resident was checked on every two hours" and he still was not located in front of a nursing station, as required by his assessment.

On June 12, two days before he died, he was again discovered on the floor, apparently after a fall. The report notes that "resident A rapidly developed a change in condition manifested by agitation and then a decrease in his level of consciousness." The next day, he was taken to an acute-care hospital in a comatose state, and within 24 hours he was dead.

Doscher's death certificate, according to the state, listed his cause of death as "accidental from falling down on his head in the bathroom," resulting in an acute subdural hematoma from blunt force trauma. Doscher, who was born in Linden and graduated as an electrical engineer from Cal Poly, San Luis Obispo, owned and operated Doscher Automatic Vending Machines in Stockton for 32 years with his late wife, Dorothy. Family members described him as an avid golfer and pilot who was a 33-degree Mason and member of Morning Star Lodge, Stockton Scottish Rite Bodies, Sciots Pyramid and Stockton High 12 Club.

"My grandfather was as strong as an ox and stubborn. Certainly I miss my grandfather. I miss him every day, and I don't think it was his time," said Doscher's grandson and namesake, Bob Doscher, 47, of Stockton.

Contact reporter Joe Goldeen at (209) 546-8278 or