"Menlo Park nursing home fined for woman’s death"
San Mateo County Times
By Banks Albach
Palo Alto Daily News
Article Created: 06/06/2008 04:14:00 PM PDT
The California Department of Public Health has nailed Atherton Healthcare, a Menlo Park nursing home, with a $100,000 fine and the stiffest citation possible after concluding its staff was negligent in the fall and subsequent death of a 48–year–old woman suffering from Huntington's chorea disease.
A manager at the facility, however, said that Atherton Healthcare has already appealed the May 12 decision and is contending that the falls were "inevitable" because of the woman's serious and progressive illness. The manager asked to remain anonymous.
"We think this should be reviewed because it doesn’t reflect what happened," the manager said. "We tried every measure that we could. This is a terrible disease."
In Huntington’s disease, brain cells degenerate, causing uncontrolled movements, loss of intellectual faculties and emotional disturbance.
The state health agency, which announced the punishment Thursday, claims that the facility at 1275 Crane St. failed to take adequate safety measures with the woman, who fell 15 times in less than a year. She died Dec. 1, 2007, a week after a staff member found a deep cut in her head while combing her hair.
A physician concluded that she must have fallen unseen sometime before Nov. 24, but stated in a log that "she does not need to be sent out for stitches because scalp wounds heal easily," according to the agency’s findings.
A different physician sent the woman, referred to as "resident
one" in the agency’s report, to an emergency room three hours later, where she was listed in critical condition and unresponsive. The San Mateo County Coroner’s Office later concluded that she died from left–sided subdural hemotoma, or swelling of the brain, and bilateral subdural hemorrhages due to blunt trauma.
Ken August, a spokesman for the agency, said citations are classified as B, A, or in this case, AA, the most severe.
"This is a very serious violation that should have been prevented," August said. "It’s the highest fine the state can hand down."
August said his agency received the complaint on Nov. 28, 2007, four days before the woman died, and completed its investigation May 2.
The state agency also recently levied an AA citation and a $60,000 fine against Care Center of Rossmoor in Walnut Creek, after staff there failed to follow protocol when a routine change of a tracheotomy tube went wrong, resulting in the death of a 56–year–old man in a coma.
In the past two years, Atherton Healthcare received three lesser fines from the agency: a $10,000 penalty for a patient rights violation in 2006, a $1,000 hit for not reporting a case of abuse in 2007 and a $20,000 administrative violation earlier this year. Regarding its most recent violation, the facility’s management is claiming innocence. The same manager said the woman’s family directed the facility not to use restraining devices on her despite repeated falls and discussions with facility physicians and staff.
"It was a directive from day one — what else could we do?" the manager said. "We give the best care we can. I believe this fall was inevitable."
If the facility’s appeal is granted by the state agency, however, Atherton Healthcare will have to do more than defend itself in the woman’s fatal fall. According to the report, "the facility failed to consistently assess, evaluate, and update the (woman’s) care plan, who had a history of falling."
The woman suffered 10 "unwitnessed" falls and was found on separate occasions with deep cuts on her forehead, eyebrow and chin, a bruised and swollen eyelid and a bruise on her nose. Before her death, she was taken to an emergency room twice for stitches and medical glue, according to the agency’s report.