Newport Nursing and Rehabilitation Center
1555 Superior Avenue, Newport Beach, CA 92663
Citation Number: 060008776
Citation Date: 11/08/2011
Violation Date: 9/6/2011
Class: AA
Penalty: $ 100,000

On 9/6/2011, a resident died after suffering a fall in the bathroom while unattended. She was found face down and unresponsive on the bathroom floor and died from a cervical spine fracture she sustained from the fall. Prior to her death, the resident had been admitted to the facility due a hip fracture caused by a fall, and the facility had assessed her as being at high risk of falls. According to her care plan, she required extensive assistance with toileting needs. Notwithstanding these needs, she was left alone in the bathroom to use the toilet on the morning of her death. Reportedly, a certified nursing assistant (CNA) took her to the bathroom and then left twice, first to check on another resident, then to find someone to cover for her so she could go to lunch. While the CNA was away, the facility's maintenance director discovered the resident unresponsive on the bathroom floor while doing an inspection of call lights. In addition to the cervical spine fracture, the resident suffered a large hematoma to her head. She died the same day after being transported to the hospital. The coroner's autopsy report showed that the cervical spine fracture she sustained in the fall was the cause of her death. The facility was cited because its failure to implement the resident's care plan and to provide adequate safety measures and supervision led to her death.