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⭒ Violation of the Month Archive

Riverside Behavioral Healthcare Center Fined $2,000 for Suicide Deaths

Following the tragic deaths of two young residents who died from suicide, the Department of Public Health (DPH) issued an outrageously small fine of $2,000 to the Riverside nursing home where they had lived. On November 10, 2016, DPH issued a $2,000 Class B citation to the Riverside Behavioral Healthcare Center, a skilled nursing facility in Riverside.

According to the citation, the residents committed suicide about four months apart from each other by tying bed sheets to fire suppression sprinklers in facility restrooms and hanging themselves.

The first suicide involved a 21-year-old male resident who died on September 10, 2014. The citation states that a separate investigation of this resident’s death was conducted but does not reveal details.

However, an earlier citation report gives some insight into circumstances surrounding his death. That citation, issued on September 23, 2015, states another resident reported that his deceased friend had confided in him he was upset because, while he was naked in the shower, a certified nursing assistant (CNA) had peeked around the corner and asked him uncomfortable questions about whether he is gay. DPH issued a Class B citation because the facility failed to immediately report the alleged incident of sexual abuse to DPH and other authorities as required. The resident’s suicide followed this incident.

The second suicide involved a 19-year-old female resident who died on January 3, 2015 in the same manner as the other resident, whom she knew. According to the citation, she had a history of suicide attempts and had made recent suicidal statements. The facility reportedly had been checking on her every 15 minutes after she had attempted to leave the facility without permission. It stopped this monitoring three days before she committed suicide.

The facility was cited for failing to prevent residents with a history of depression or suicide attempts from attempting suicide by hanging themselves from the fire suppression sprinkler heads located in its restrooms. The citation states the facility considered installing sprinkler heads that were flush with the ceiling after the first resident’s suicide to prevent future suicide attempts, but it had not taken any action by the time of the subsequent suicide on January 3, 2015.

The administrator stated there was no increase in monitoring of the resident population implemented from September 10, 2014 through January 3, 2015.

California law authorizes DPH to issue Class AA citations with fines up to $100,000 in instances where residents’ deaths are caused by neglect. The DPH citation does not explain why it did not exercise this authority.

Nor does the citation explain why the suicide victims were confined to a nursing home.

Violation of the Month Archive