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Pilgrim Haven fined $100,000 in resident's death

Santa Cruz Sentinel
Diana Samuels
August 4, 2010

The Pilgrim Haven retirement community in Los Altos has been hit with the state's stiffest penalty for failing to properly supervise an 85-year-old man who died last year after a fall, the California Department of Public Health announced Tuesday.

Pilgrim Haven received an "AA" citation and will be fined $100,000, the maximum amount allowed under state law, according to a statement from the department.

Rae Holt, Pilgrim Haven's executive director, said the retirement community disagrees with the health department's findings and plans to appeal the decision.

According to a state report detailing the investigation, the 85-year-old man had lived at Pilgrim Haven for almost 2 1/2 years before he fell on Dec. 7, 2009.

He needed help walking, and had fallen once a couple of months earlier, on Oct. 3. At the time, Pilgrim Haven staff noted that he sometimes didn't use his walker.

When the man fell again Dec. 7 at about 11 a.m., a nursing assistant in another room heard him calling for help and found him sitting on the floor with his walker in the middle of the room, according to the state report. The man said he fell, but didn't hit his head.

A nurse began a series of neurological assessments, checking many times throughout the day, and at first the man appeared fine. But at about 4:30 p.m. he turned pale, the report says, and three hours later he vomited. By 9:30 p.m. he was unresponsive. He was taken to Stanford Hospital at 11:30 p.m., where he died of brain injuries.

The state report faults Pilgrim Haven for not monitoring the placement of the man's walker and for failing to supervise a resident who had a history of falls and of not using his walker. In addition, the report says Pilgrim Haven did not have a registered nurse on duty in the evening to do "accurate and consistent assessment" of the man after his condition worsened.

Also, after the man became ill, the licensed vocational nurse on duty did not document that she checked him for head injuries. The nurse said she took vital signs and assessed his neurological condition, but spent most of her time on the phone with a doctor and the man's family and forgot to write it down.

"The above violations presented an imminent danger to the patient, and was a direct proximate cause of death of the patient," the report says.

Pilgrim Haven is conducting in-services with its staff to review policies on resident falls, according to the report.

Holt, the executive director, said he could not discuss specifics of the case.

"We feel that we responded appropriately and complied with the regulations," he said.

Pilgrim Haven has a five-star "Much Above Average" rating from the public health department and has not been cited since at least 2004, according to state records.

E-mail Diana Samuels at