San Francisco – The California Department of Public Health (DPH) recently issued citations to three Orange County nursing homes for neglect that caused the deaths of their residents. The citations were issued to Kindred Health Care Center of Orange, Villa Valencia Health Care Center of Laguna Hills and Evergreen Fullerton Healthcare.
On January 20, 2010, DPH issued an AA citation with a fine of $85,000 to Kindred Health Care Center of Orange. According to the citation, a resident died on July 18, 2009, after suffering a fall and fatal head injuries. The resident had a history of falls before and after entering the facility and a history of brain surgeries that put him at high risk of injury due to falls. The facility planned preventative measures but they were not in use at the time of the fall that led to his death. The Department found that Kindred’s violations were a direct proximate cause of the resident’s death.
An AA citation is the most severe citation issued by DPH and indicates a resident died due to the facility’s negligence. DPH issues very few AA citations.
On December 9, 2009, DPH issued an AA citation with a fine of $100,000 to Villa Valencia Health Care Center of Laguna Hills. According to the citation, a resident fell on July 30, 2009, after getting out of bed to go to the bathroom, hit the foot of her bed, and suffered a serious head injury that caused severe bleeding and brain damage. She was hospitalized and died the next day. A family member of the resident reported she called him the evening before her fall reporting no one was answering her call light. He also reported the facility had not discussed any plans to prevent falls during a care plan meeting held three days before her death even though the resident had suffered an earlier fall and injuries that same week.
Villa Valencia was cited for several violations that led to the resident’s death, including its failure to provide a safe environment, failure to implement its care plan to use an alarm to alert staff if the resident attempted to get out of bed, failure to develop a comprehensive care plan and failure to assess the resident’s risk for injury from a fall due to her use of a blood thinning medication.
On November 18, 2009, DPH issued an A citation with a fine of $15,000 to Evergreen Fullerton Healthcare. According to the citation, a resident died less than an hour after being hospitalized due to deteriorating vital signs and a decreased level of consciousness after a nursing assistant accidentally pulled out his feeding tube a day earlier. The licensed nurse who replaced the feeding (gastrostomy) tube reported it took her five attempts to do so successfully, but the resident’s physician was not notified of these difficulties. The resident’s wife, who was visiting her husband when the feeding tube became dislodged, reported “we told them again and again not to put the tube back… he needed to go to the emergency room… the doctor who put it in said if it came out to have him go to the emergency room to have it put back in… they refused to listen to us.”
The physician who surgically placed the feeding tube confirmed that it should not have been replaced without physician intervention. A detective with the Orange County Coroners Department reported that the resident’s cause of death was acute peritonitis (infection of the lining of the abdomen) secondary to dislodgement of the feeding tube.
An A citation is issued when violations present imminent danger to residents, or the substantial probability of death or serious harm.