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⭒ Violation of the Month Archive

Resident at the Chino Valley Health Care Center Killed by Roommate with Psychiatric Problems

A 91 year old resident died on 12/4/2010, eleven days after being assaulted by his 46 year old roommate while in bed. Facility staff found the victim in bed on the morning of 11/23/2010 with his face bloodied and swollen and his right arm pointed up over the right side rail while his right forearm was twisted around and pointed down between the bedside rail and mattress, with his humerus bone fully exposed and right elbow joint totally displaced. His roommate was sitting at the foot of the bed with blood on his hands and gown. The victim was transferred by EMS helicopter to a hospital where he remained until he died. An autopsy report revealed that the resident suffered facial trauma and multiple blunt force injuries that led to amputation of his right arm and caused his death. The deputy medical examiner ruled that the resident’s death was a homicide.

The resident who assaulted him had a history of psychiatric treatment, hospitalizations due to destructive behavior, and aggressive, physically abusive behavior to others. The nursing home’s records documented that the resident had more than 150 episodes of sudden angry outbursts during the 10 week period prior to 11/23/2010 when he attacked his roommate. The facility was cited because it did not appropriately address this resident’s aggressive behaviors and failed to protect the victim from physical abuse that caused severe injuries and his death.

It should be noted that the Department of Public Health (DPH) waited well over three years before issuing the citation after it began its investigation.

Violation of the Month Archive