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⭒ Violation of the Month Archive

Resident Dies after Multiple Falls and Use of Chemical Restraints at Bethel Lutheran Home

In May of 2016, a female resident died due to injuries sustained from multiple consecutive falls at Bethel Lutheran Home in Selma, CA. The resident had dementia, and despite her high risk for falls, she was left unsupervised and allowed to fall while walking alone into her room on 5/16/16, resulting in multiple facial fractures, bleeding to the brain, and stitches on her scalp.

She was hospitalized and readmitted to the nursing facility the following day.

Upon readmission, the resident demonstrated discomfort due to the stitches on her face. Rather than address her underlying pain, the staff administered Ativan, a powerful psychoactive medication used to treat anxiety, and commonly used as a “chemical restraint” to sedate residents in nursing facilities. Then, the very next day, 5/17/16, she fell again while unsupervised.

The facility was unable to produce any evidence that they monitored her every 30 minutes as directed by her care plan after the first fall.

She died seven days later from injuries sustained from the fall.

Violation of the Month Archive