On February 1, 2019, the California Department of Public Health issued a Class AA citation to Long Beach Healthcare Center and fined it $100,000 for neglect that led to the death of a long-time resident on September 11, 2018. The rare Class AA citation was triggered by a complaint that the resident had been neglected and was not brought to the hospital timely.

The resident, who had lived at the facility for 16 years, suffered from multiple disabilities and was completely dependent on the facility for care.

On August 30, 2018, the resident was hospitalized due to respiratory failure and a severely distended abdomen. She was unresponsive, intubated and placed on a ventilator. When a new urinary catheter tube was inserted, approximately 200 cc of thick creamy brown urine drained from her bladder into the catheter tubing. X-rays showed large amounts of stool within her colon. She remained in the hospital until her death on September 11, 2018, which was caused by acute respiratory distress and severe sepsis.

The facility neglected the resident prior to hospitalization. She had no bowel movement for seven days but no assessment was done. The facility did not develop or implement a care plan for her catheter. It did not monitor her as her condition deteriorated. The facility failed to immediately call 911 or consult with her physician when her condition changed. These failures led to a delay in the resident’s diagnosis, care and treatment.

Her family members described the neglect. One of them stated: “She died because of negligence in the facility where she resided for over 16 years…On the morning that she was transferred to the hospital, she was so dirty with a very bad odor and her abdomen was as large as a nine-month pregnant woman.”

Another family member stated: “I visited the resident very often and her condition was deteriorating and was foul smelling. Her stomach was so big, as if she had three soccer balls inside of her stomach due to accumulation of fecal matters. The facility was not taking good care of the resident.”

The Long Beach Healthcare Center is one of 28 California skilled nursing facilities that CMS has currently classified as Special Focus Facility candidates due to continuing failures to meet required care standards.

Download the pdf of this citation HERE.
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