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An elderly resident fell 24 times in a year.
His Sacramento care facility faces $10,000 fine

By: Hannah Holzer
Sacramento Bee
September 5th, 2018

Alan Owen Nelson fell 24 times during his 12-month stay at Carlton Senior Living, an assisted living facility in the Sacramento suburbs.

Nick Alexander was visiting his stepfather Aug. 28, 2016, at Carlton Senior Living, an assisted living facility in the Sacramento suburbs. He was concerned about Alan Nelson, who had fallen numerous times at the facility, and Nick Alexander was frustrated that no changes were being made.

Nelson’s doctor prescribed the placement of alarms on his wheelchair and bed to alert staff at the facility when he was up and to reduce the potential for a fall. But no alarms had been installed, even though the family asked for them repeatedly.

So during that visit in August, Nick Alexander asked the director of his stepfather’s care unit when the alarms would be installed. He was assured a staff member was working on it and placement would be immediate.

Just hours after the meeting, Alan Nelson had his most devastating fall.

“Four hours later, there was a message on my phone saying Alan had had a really bad fall,” Alexander said. “And that’s in the death certificate — the injury (from) that fall, to Alan’s skull and brain — is listed as one of the contributing causes of his death.”

He suffered fractures to his left frontal skull and left nasal bone and had a brain bleed, according to state documents.

Nelson died, at the age of 76, five weeks later.

Angered by the care his stepfather had received at the facility, Nick Alexander and his mother filed a complaint with the state. That led to state findings that Nelson had 21 unwitnessed falls and three witnessed falls in 12 months.

“There were a number of falls (Carlton) didn’t even report to us; we only found out about them from the report from the state,” Alexander said. “We didn’t know that there were nearly as many falls as there were.”

An investigation by the California Department of Social Services concluded that the facility had failed to provide proper and necessary care and supervision, resulting in numerous falls and subsequent injuries.

Ultimately, the state decided to issue an enhanced penalty of $10,000.

Lisa Schumann, Carlton’s regional vice president of operations, responded to the penalty with a statement.

“Carlton Senior Living has been providing seniors with high quality care in a home like environment for more than 30 years,” the statement reads. “We are committed to protecting residents’ privacy and as such cannot comment on a particular resident’s care. We value our relationship with the Department of Social Services and share DSS’s commitment to improving the health and safety of our residents.”

According to the department’s website, Carlton Senior Living, formerly Carlton Crown Plaza, has received nine Type A citations, for placing an individual’s immediate rights, safety or health in jeopardy, and 10 Type B citations, for impacting an individual’s rights, safety or health.

The majority of the Type A and B citations issued by the state are the result of investigations conducted in response to complaints.

Alan Owen Nelson

Alan Owen Nelson was born in a small town in Minnesota and is described by his family as a kind, friendly and gentle person. He worked as a salesman and liked to tell jokes and play tennis.

Described as an athletic person by his wife, Dr. Sharon Alexander-Nelson, Nelson began to notice that even though he would workout, he couldn’t get stronger. He became breathless going up stairs and he had low blood pressure and would get dizzy and fall.

After he was diagnosed with Parkinson’s disease and dementia, his wife determined she could no longer provide her husband with the care he needed, and she thought Carlton was the best solution.

The assisted living facility is off Fulton Avenue in the Arden Arcade area of Sacramento County, just two blocks from the couple’s home, and Sharon Alexander-Nelson visited her husband of 36 years nearly every day. He moved into Carlton in September 2015 with a note from his doctor: high risk for falls.

Over the course of his stay there, Alan Nelson lived in three different living areas within the facility. He started out in an assisted living unit in the front.

“He seemed to be all right, he had friends there and there were things for him to do,” Alexander-Nelson said. “He did what he thought — that I thought — was the best.”

At home, Alan Nelson could use a railing to get out of bed. But at the facility, that wasn’t allowed.

“They had rules that I didn’t understand,” Alexander-Nelson said. “But they were supposed to take care of him carefully and we paid a lot of extra money for that.”

As Nelson’s care became more advanced, the financial cost to his family increased. Generally, long-term insurance provided around $4,000 a month. In addition, the family paid an estimated out-of-pocket cost of $4,000 every month.

Documents both obtained by The Bee and posted online by the California Department of Social Services’ complaint investigation show Nelson had four falls in 92 days between October 2015 to January 2016 resulting in abrasions to his scalp and head, neck and side pain.

Then, from early January to late February, he had five falls in 52 days, resulting in bleeding and abrasions to his head.

Department documents say Nelson’s nurse had suggested a number of possibilities to lessen the impact of a fall: “bed/wheelchair alarm, pendant alarm, assessment of possible causes of frequent falls, providing supervised and assisted ambulation, 24-hour personal caregiver” or a “protective mattress on the floor.”

The department found Carlton didn’t do anything.

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