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"Nursing home fined $100,000"

Original source:

The Press–Enterprise

PATIENT’S DEATH: It’s the state’s most severe citation. It comes after workers failed to follow up on a woman's injury.

07:22 PM PDT on Wednesday, August 27, 2008
The Press–Enterprise

The Hemet nursing home owned by Valley Health System has been fined $100,000 and issued a AA citation after a patient died two days after suffering a blow to her head.

The fine and citation issued to Hemet Valley Healthcare Center are the most severe that investigators with the California Department of Public Health could issue to a nursing home.

It is at least the second AA citation and fine to be issued to a Riverside County nursing home this year. In March, inspectors cited and fined The Springs at the Carlotta in Palm Desert after a patient died of an infection from a perforated colon.

An AA citation is issued when the inspector can show that the nursing home’s action or inaction was a direct cause of a patient’s death. In response, the nursing home is required to come up with a plan of correction showing how it’s going to prevent something like this from happening again. Then, the department has to accept it.

The citation report shows that Hemet Valley Healthcare Center was cited and fined Aug. 20. Steven Collier, the facility’s interim administrator, signed the report.

Neither Collier nor Fred Harder, CEO of Valley Health System, could be reached Wednesday.

Ken August, spokesman for the state Public Health Department, said Hemet Valley Healthcare Center immediately submitted a plan showing how it will correct problems listed in the citation. The department approved the plan, he said.

Department records show that facility officials didn’t report the woman’s death to state authorities even though they knew about it. Before last week, the nursing home hadn’t been fined or cited in at least four years.

Hemet Valley Healthcare Center, a 433–bed facility at 371 N. Weston Ave., was cited for failing to follow its patient assessment procedures and immediately contact a doctor after the unidentified 81–year–old woman hit her head on a bed rail, the report states. The woman was taking two blood thinners, either of which increases bleeding risk if a patient is injured.

She died two days after the blow from bleeding on her brain, according to the report.

The citation and fine come in response to a complaint filed earlier this year by Joseph Baroncini, of Hemet, and his sister, Alda Norris, of Oceanside. Their mother, Olga Baroncini, died Sept. 16, 2007, at Loma Linda University Medical Center and is the unidentified woman in the report.

On Wednesday, Norris said she and her brother had been instructed by an attorney not to comment on the fine and citation.

According to the report, the unidentified woman was sent to Hemet Valley Healthcare Center to recover from colitis, deep venous thrombosis and pulmonary embolus, the report states.

Her medical record did not include a head injury she suffered Sept. 14 during physical therapy until her son found out about it and reported it later that day. He said his mother told him that she hit her head on the back of a chair as she was being helped by a physical therapist, the report states.

A note in the woman’s file indicates that she hit her head on a bed rail, the report states. The physical therapist told inspectors he didn’t report the injury because he didn’t think it was serious, according to the report.

Then, the nurse who was on duty didn’t follow facility procedures and check the woman for changes in her condition or report the head injury to a doctor because she didn’t think it was "anything big," the report states. The facility fired the nurse more than a week after the woman died, the report said.

The woman lost consciousness the next day after her blood pressure dropped and her pulse increased, according to the report. She was taken to a hospital and transferred to a second, where she was taken off life support and died.

The report states the woman’s death may have been prevented if a doctor had been told about her head injury so tests could have been performed sooner and she could have been taken off blood thinners.

Nursing home industry officials and patient advocates said it is unconscionable that nursing home employees chose not to follow facility procedures put in place to protect patients.

"That’s part of the problem when they think they have discretion to follow rules and regulations," said Pat McGinnis, executive director of California Advocates for Nursing Home Reform, a consumer protection organization.

Betsy Hite, spokeswoman for the California Association of Health Facilities, said Hemet Valley Healthcare Center isn’t a member of her professional organization. Generally, she said, all nursing home employees, from housekeepers to administrators, are obligated to report injuries and deaths to state officials.