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Deaths of Santa Monica Nursing Home Residents from Neglect Result in Minimal Penalties from Licensing Officials

One nursing home resident died while nursing staff ignored his breathing difficulties. Another resident died after being hospitalized with an infected bedsore. A third resident was hospitalized with a neglected bedsore. Dozens of complaints have been filed against the same facility. Yet, Arbor View Rehabilitation and Wellness Center, a Santa Monica nursing home, continues to avoid serious penalties and Licensing officials continue to issue minimal fines and investigate serious neglect many months after complaints are filed.

Scroll to the bottom of the page to download complete copies of the citations.

On February 24, 2009, a 78-year old Arbor View resident died after being held down by nursing staff who were treating a skin wound. The victim was having difficulty breathing at the time and suffered from excessive secretions caused by Parkinson’s disease; however, the nurses failed to clear his airway before lowering his head to perform the skin treatments. He stopped breathing within minutes after the care started and was pronounced dead within the hour.

According to a citation issued by the California Department of Public Health, an LA County Health Department investigator was at Arbor View and observed the resident gurgling and struggling to breath. The investigator immediately conducted an investigation of the neglect that led to the resident’s death, leading to a citation issued on March 12, 2009. The citation describes the facility’s failure to follow its own policies and failure to develop an appropriate care plan for the resident’s excessive secretions.

Despite the tragic outcome and the investigator’s first-hand observations, the Department of Public Health (DPH) issued Arbor View its lowest-level citation (class “B”) and fined it just $1,000. California law permits DPH to issue fines of up to $100,000 for neglect or abuse that causes a resident’s death.

During the same day the resident died (February 24, 2009), the LA County Health Department investigated a complaint involving an Arbor View resident who was hospitalized due to a severe, infected bedsore in August 2007 and later died. Although it found that Arbor View failed to provide appropriate care, DPH again issued a mere $1,000 fine and a class “B” citation on March 11, 2009 – a year and a half after the death of the resident.

On March 13, 2009, DPH issued a third citation to Arbor View for neglecting a resident who was hospitalized in December 2007 due to a severe bedsore and other health problems. It was cited for failing to provide sufficient care to prevent bedsores. As in the other two cases, DPH issued a class “B” citation with a $1,000 fine.

It is common for DPH to issue very small fines for severe neglect and abuse. Of equal concern, DPH only collects a small percentage of the fines it issues to nursing homes. According to its records, it has collected less than a third of the fines it has issued in the last three years.

Although California law and a court order obtained by CANHR require DPH to begin onsite investigations within 10 working days of receipt, the investigations of the two bedsore complaints were conducted 15 to 18 months after the complaints were filed.

According to the DPH website, Arbor View was the subject of more than 75 complaints during 2007 and 2008. The federal Centers for Medicare and Medicaid Services (CMS) has given it a 1-star rating (much below average) that is posted at Arbor View is owned by Grancare, a nursing home chain based in Atlanta, Georgia.

Full Citations (pdf):