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"Chico nursing home fined $100,000"

By LARRY MITCHELL – Staff Writer
Article Launched: 04/24/2008 12:00:00 AM PDT

CHICO — A nursing home has been ordered to pay a $100,000 fine in connection with the death of an elderly resident.

The fine was levied against Twin Oaks Health and Rehabilitation Center by the state Department of Public Health.

Jason Smith, a spokesman for Evergreen Healthcare Management, which owns the Chico nursing home, said he couldn’t comment on the citation because of rules that protect residents’ privacy.

A document from the Department of Public Health indicated Evergreen is appealing the citation.

The resident who died, a 98–year–old woman, slipped out of her wheelchair and was strangled by a belt that was supposed to keep her in the chair, according to documents from the Department of Public Health.

The woman, who had to use a wheelchair, moved into Twin Oaks in February of last year. She’d been diagnosed with Alzheimer’s, anxiety, depression, weakness and psychosis, according to state documents.

Often, she would slip down in her wheelchair. Staff members had to watch her and pull her up when that happened, the documents said. For a time, a device called a pummel cushion was used to help keep her in the chair, but for some reason its use was discontinued. A restraint called a "soft waist belt" was used to help prevent her from falling out of the chair.

During supper on Dec. 7, the woman kept sliding down in her wheelchair. It happened so many times that two certified nurse assistants (CNAs) who were working in the dining room decided to put her to bed immediately, documents stated.

The two CNAs, who weren’t regular staff members but had been hired through a registry to work temporarily, were taking the woman to her room when they were stopped by a family member of another resident, who asked them to put that resident to bed first.

According to documents, the two CNAs said they thought the woman in the wheelchair would be all right by herself for a little while, so they left her in the doorway of her room and attended to the other resident.

Twenty to 30 minutes later, the documents said, the two CNAs came out into the hall and noticed that the door was closed to the room of the woman in the wheelchair. They opened the door and saw the woman on the floor with the waist belt pressed against her neck and chest, the documents stated. She wasn’t breathing.

The nurse assistants began performing CPR, but a nurse who had been called told them to stop because the woman had left instructions that she was not to be resuscitated, the documents said.

Twin Oaks reported the incident to the Department of Public Health, which investigated. The nursing home was issued a Class AA citation for failing to keep the resident safe and not providing adequate supervision.

Class AA citations are the most serious the state issues. They carry a fine of between $25,000 and $100,000.

The nursing home was required to develop what’s called a plan of correction. In its plan, the Twin Oaks administration said the entire staff, including employees hired through registries, would be instructed that residents’ safety must take priority over all other concerns.