The California Department of Public Health (DPH) issued an AA citation and $100,000 fine to Arbor View Rehabilitation and Wellness Center for causing the death of an 88 year old resident. Arbor View is a skilled nursing facility located in Santa Monica that was fined earlier this year for neglecting other residents who died.

According to the DPH citation, a hospital inserted a gastrostomy tube into the resident’s stomach on August 29, 2008 to allow her to directly receive nutrition, fluids and medications. The resident was readmitted to Arbor View on September 3, 2008.

The resident’s feeding tube became dislodged at Arbor View on September 8, 2008. A licensed vocational nurse (LVN) reinserted it and continued the resident’s tube feedings. The resident was hospitalized the next day due to vomiting, nausea and other symptoms. A hospital scan found that the feeding tube had been inserted into her abdominal cavity instead of her stomach and showed massive amounts of fluid in her abdomen.

The resident did not recover and died on October 24, 2008. An autopsy report indicated that she died due to complications of inflammation of the lining of her abdominal cavity.

Arbor View’s policy on gastrostomy tubes permits licensed nurses to change or reinsert these tubes only when they are in place for three months or more. The resident’s tube had only been in place for about 10 days. Hospital orders stated that the radiology department should reinsert or replace the tube if it fell out to ensure proper placement.

A family member stated that the resident had been doing well until the nurse removed and reinserted the feeding tube in the wrong place.

The citation states that Arbor View’s violation was a direct proximate cause of the resident’s death.

The $100,000 fine issued in this case is the most severe allowed by California law.

Arbor View is the subject of an April 21, 2009 CANHR press release on neglect that caused the deaths of other residents. In those instances, DPH issued low level citations and very small fines. To see CANHR’s press release on those citations, CLICK HERE.

Full Citation (pdf): 91-1083-0006173-S