Aviara Healthcare Center
944 Regal Road, Encinitas, 92024
Citation Number: 080006270
Citation Date: 6/9/2009
Violation Date: 4/28/2009-5/10/2009
CLASS AA CITATlON -- PHYSICAL ENVIRONMENT
42 C.F.R. 483.25 (h) Accidents. The facility must ensure that:
(1) The resident environment remains as free of accident hazards as possible.
On 5/9/09, the facility placed a tab alarm on a resident's gown after he fell to alert staff if he got out of bed. About 21 hours later, the resident fell a second time, leading to his death. Although the tab alarm should have sounded, the resident got out of bed during the middle of the night without any staff responding. He lost his balance as he left the room and grabbed on to a mechanical lift that staff had left in the hallway outside his room. The resident fell, pulling the mechanical lift down onto the floor, striking his head on the metal frame of the mechanical lift. This fall caused such a severe bleed in the resident's brain, that the entire brain was pushed one third of an inch past the center point of his brain to the right side. He died three days later due to blunt force trauma to the head. The resident had been admitted to Aviara Healthcare several days before the fall for rehabilitation of a fractured hip, and had been doing well in therapy. The facility's decision to store a large piece of equipment which is easily overturned in the hallway led to the resident's death. The facility was notified on 5/13/09 that the mechanical lift posed a danger to residents and facility staff stated that the lift was to be stored in the shower room when not in use. However, the lift was still in the corridor four days later during a follow-up investigation.