On 9/18/06, a 62 year old resident died after being hospitalized due to renal failure, sepsis, pneumonia,acute respiratory failure, circulatory shock, dehydration, hypoglycemia and hypotension. The resident was admitted to Placerville Pines in July 2006 and was initially doing well in therapy and expected to return home. During the week before his death, the resident complained of feeling poorly, ate and drank little, had poor vital signs and significantly abnormal blood values. The facility notified his physician that he had signs and symptoms of pneumonia on 9/12/06. The physician said he did not recall being notified about the resident's low blood pressure of 60/40 and was frustrated that he was not notified about the resident's decline in a timely manner. The physician stated that if he had known the resident's condition had worsened, he would have sent him to the hospital on 9/12/06, two days before he was actually hospitalized. After a family member raised concern on 9/14/06 about the resident's dire condition, the resident was hospitalized in an altered state of consciousness.
The facility was cited because it failed to adequately assess the resident and failed to notify the resident's physician of a significant change in his condition,resulting in a lack of medical advocacy for the resident and a delay of acute care assessment. These failures were a direct, proximate cause of the resident's death.