"New Hope nursing home hit with stiff fine after a death"
By Jennifer Wadsworth
08.27.09 - 06:03 pm
A 78-year-old woman died last year because a Tracy nursing home failed to properly monitor her medication and failed to check her into an emergency room fast enough when her brain started bleeding, according to state regulators.
The California Health and Human Services Agency fined New Hope Care Center $100,000 after an investigation into a report that the nursing home at 2586 Buthmann Ave. ignored the worsening condition of a patient admitted a year ago with a hip fracture, heart problems osteoporosis, hypertension and osteoarthritis.
State investigators concluded that New Hope caregivers “failed to ensure that the resident’s medications were monitored and failed to fully assess the resident or promptly notify the physician when there was a change in the resident’s condition, which resulted in the resident’s death,” according to Al Lundeen, a spokesman for the state agency.
The fine levied on the nursing home is the maximum penalty the agency can impose for a “AA” citation, the harshest assessment for hospitals and nursing homes in California.
Employees of the 5-year-old for-profit nursing home declined to comment on the state’s findings. New Hope’s corporate owner Evergreen Healthcare Companies, LLC, did not return phone calls seeking comment.
According to the state, caregivers failed to keep a close eye on the condition of the patient — whose identity was withheld in the report — after a doctor ordered an increase in medication to prevent blood clots. A possible side effect of the medication is excessive bleeding, according to the regulatory agency.
Because the nursing home staff didn’t monitor a change in the woman’s condition after the doctor upped her anticoagulant prescription, the state said they missed warning signs that could have saved the woman’s life.
On Sept. 14 last year, days after the doctor-ordered increase in her blood-thinning medication, the woman started slurring her words and complaining of a headache, according to relatives who visited her that morning.
“Things did not seem right with her,” the woman’s daughter told the state agency, according to the report accompanying the citation. The woman’s husband said the patient couldn’t talk “because she had a bad headache … and was repeating, ‘my head, my head.’”
Even though the woman woke up just a couple hours earlier, she started nodding off, waking up only to vomit. Her husband complained that the nursing home employees didn’t treat the situation as an emergency. He “felt like the staff was not taking her condition as seriously as he knew they needed to,” according to the citation.
The woman died that day in the emergency room of a Tracy hospital. The patient’s death certificate cites “….inappropriate bleeding or clotting secondary to medication” with hypertension and bleeding in her brain as her cause of death.
New Hope has a spotty public history.
Nursing Home Compare, a government Web site run by Medicare, gave the facility one star out of a five-star ranking — that’s “much below average” — for an assessment that looks at health of patients, safety, staffing, quality of care and other criteria.
The health and human services agency issued a citation and a $1,000 fine in February last year after determining that the nursing staff failed to properly monitor the facility’s infection-control policy. A complaint from July last year says that several patients accused New Hope nurses of walking right past them when they ring the call button.
Sources within the agency have confirmed that there’s an ongoing investigation into New Hope that may end in a second “AA” citation stemming from complaints filed by Tracy resident Paula Baca about medical negligence toward her mother.
“We do have other complaint investigations (connected to New Hope) that are ongoing, but at this time it is too preliminary to disclose information, so that’s all we can say about that,” said Ralph Montano, spokesman for the state’s health agency. “It’s also far too early to speculate as to the outcome of those investigations.”
Baca’s mom stayed at the nursing home between 2006 and 2007. She didn’t die at New Hope, but her health certainly worsened because of her stay there, according to Baca.
“They totally ignored my mom,” Baca said of her 74-year-old mother, whom she transferred to another nursing home months before her death last year after filing complaints against New Hope for allegedly failing to treat her mom’s serious skin infection. “When doctors finally inspected her, they found she had bone marrow cancer, E. coli and a blood infection, among other things.”
The state issues about 20 AA citations a year to California’s 1,300 registered nursing homes. That’s about 1.5 percent of nursing homes in the state.
Several complaints along with the citation history of the nursing home — which averages a citation and several complaints a year — is available on the health and human services Web site at hfcis.cdph.ca.gov.
•Contact Tracy Press reporter Jennifer Wadsworth at 830-4225 or firstname.lastname@example.org.