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The story behind that 'AA' penalty: Poor care and a patient's death

Original source:

Center for Health Reporting, California Healthcare Foundation
Deborah Schoch
February 22, 2012

Four times before, the woman had been admitted to the Downey nursing home with a diagnosis of diabetes. Each time, the staff checked her blood sugar levels at least once a day and gave her regular doses of insulin.

During her fifth stay, however, her care went awry. For 29 days, no one measured her blood sugar. She grew seriously ill and was rushed to a local hospital where she died. Doctors determined that a main cause of her death was diabetic ketoacidosis, caused by low insulin levels.

That’s why California officials announced Tuesday that they have issued a so-called “AA” citation to Downey Care Center in Downey, a Los Angeles suburb, along with an $80,000 fine.

One might imagine that such citations are rare. They’re given out only when poor nursing care leads directly to a patient’s death.

But in fact, the state Department of Public Health, which licenses and polices the state’s nursing homes, issues about 20 “AA” citations a year. Patient advocates say that’s 20 patient deaths too many.

On Tuesday, state officials made public an investigation report showing that the Downey center’s nursing staff said that they did not check the patient's blood sugar or supply her with insulin because an order to do so wasn’t in her files. Nor did they notify her doctors that the order, part of her protocol in previous visits, was missing, the report states.

Managers at the Downey center say they have changed their rules so that all patients admitted with diabetes are reviewed to determine their needs for blood glucose monitoring and medication, according to the report.

State officials also announced this week that that they’ve slapped two other Los Angeles area nursing homes with “AA” citations: Motion Picture & Television Hospital in Woodland Hills, which is being fined $80,000, and Fountain View Subacute and Nursing Center in Los Angeles, which got a $75,000 fine.

At both homes, patients died after serious falls that the state blamed on inadequate care and supervision. Fountain View got another “AA” citation in 2005 and was fined $70,000, state records show.

In December, the state issued “AA” citations to two nursing homes in Orange County. In one case, the staff at Emeritus Yorba Linda did not supervise a patient during meals and chop her food as ordered by her doctor. She choked on a large piece of meat that stuck in her throat.

While the state publicizes its “AA” citations, it also hands out hundreds of less stringent penalties to nursing homes each year.

It can issue “A” citations if poor care causes “immediate danger of death or serious harm to patients….or substantial probability of death or serious physical harm.” And “B” citations go to nursing homes where poor care is related directly to “patient health, safety, or security.”

The state gave nursing homes 21 “AA” citations, 117 “A” citations and 545 “B” citations in 2009-10, the latest year for which records are available.

It issued a total of 103 “AA” penalties in the five years ending in 2010, with fines reaching $100,000. In other words, at least 103 patients died due to inadequate care.

A $100,000 fine might seem paltry in a “AA” patient death case. But raising fines isn’t the answer, said Patricia McGinnis, executive director of the San Francisco-based California Advocates for Nursing Home Reform.

“What we need is more enforcement. They need to put a ban on new admissions until a home cleans up its act,” McGinnis said. And if a nursing home’s managers don’t make the needed changes, she said, “The state can put in a temporary manager who will.”

The state publishes an online list of nursing homes with recent “AA” citations by county, as well as information, including penalty records, for each nursing home in California.

UPDATE: Both the Downey center and Fountain View have appealed their AA citations in state Superior Court in Los Angeles County, a state spokesman wrote in an email. The Motion Picture & Television Hospital did not appeal the citation, choosing instead to pay its fine within 30 days. That meant the home only had to pay 65 percent of its fine, or $48,750.