San Tomas Convalescent Hospital
3580 Payne Avenue, San Jose, CA 95117
Citation Number: 070006439
Citation Date: 8/18/2009
Violation Date: 8/24/2009
Class: AA
Penalty: $ 80,000

On 4/3/09, an 83-year-old resident with Alzheimer's disease fell and suffered fatal injuries while walking unobserved in her room, about 3 minutes after an aide put her to bed. The aide reported he heard a loud crash and found the resident lying on the floor of her room on her back, underneath a dresser and large flat screen TV. She sustained skull fractures and bleeding within the brain. She died on 4/16/09. The death certificate indicated the immediate cause of death was from blunt trauma to the head. Facility records revealed that the resident had fallen 7 times in the last month and had suffered earlier injuries. The facility was cited because it failed to provide adequate supervision, failed to provide a safe environment, failed to update the resident's careplan to include her need for assistance when walking, and failed to implement careplan interventions to monitor her at all times and the use of a personal alarm. These failures led to the resident's death.