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"Nursing home draws severe citation, maximum fine"

Original source: by The Union–Tribune

By David Hasemyer, Union-Tribune Staff Writer
7:14 p.m. June 22, 2009

ENCINITAS – A nursing home has been hit with the most severe citation – and the maximum fine of $100,000 – in connection with a patient who died from a preventable fall, state health regulators said Monday.

The patient, who was not identified, was recovering from hip surgery at Aviara Healthcare Center on Regal Road in Encinitas.

He was admitted to the facility in April for physical therapy, and he fell twice there within 24 hours between May 9 and 10.

After the first fall, the Aviara staff put an alarm on the patient’s gown. Despite the alarm, no staff member responded when the patient got out of bed and walked into the hallway.

The wall in that area lacked a handrail, so when the man began stumbling, he grabbed a large mechanical device used to lift residents out of bed.

He fell and pulled the equipment down to the floor with him, and his head hit the metal frame of the lift, according to a report by the California Department of Public Health. The patient was hospitalized and died May 13 from the blunt-force trauma.

Seven Aviara employees said the lift was supposed to be kept in a shower room and not the hallway. Even after the man’s death, a state health investigator found the lift still stored in the same hallway location.

"The facility’s decision to store a large piece of equipment which is easily overturned in the hallway could and did pose a hazard to patients," the state report said.

David Sneddon, Aviara’s administrator, said the death was a tragic accident. He declined to talk about the patient or specific issues raised in the state investigation.

"We are always looking at making patient care better," Sneddon said. "It is something we take very, very seriously."

Aviara also was fined $16,000 because it failed to closely monitor a patient who wandered away from the facility three times within nine hours last month.