Golden Livingcenter - Shafter
140 E.Tulare Ave, Shafter, CA 93263
Citation Number: 120006570
Citation Date: 3/2/2010
Violation Date: 8/5/2010
Class: AA
Penalty: $ 100,000

On 10/19/08, a resident suffered a fall that led to her death. She fell while attempting to walk to the bathroom at night and was found on the floor of her room. A certified nursing assistant (CNA) said the resident had been going to the bathroom about every 10 minutes that night, but the CNA didn't tell the nurse. The resident was taken to the hospital, which discovered she had a urinary tract infection and fatal injuries from the fall. The resident suffered multiple fractures and a blood clot in her brain that led to her death 4 days later. The resident had fallen five times previously during the prior 10 months at the facility and was taking Coumadin, a blood thinning medication that carries great risks of falls and fatal bleeding for elderly persons with dementia. The staff wrote generic precautions into her care plan after the earlier falls, but did not implement safety precautions. Her physician said she should not have been on the Coumadin due to her history of falls, that he was not aware of the circumstances leading to her death, and he had not been involved in developing her care plan. Golden Living's director of nursing told the investigator, "Residents have the right to fall." The facility was cited because its failures to assess and respond to the resident's needs were a direct proximate cause of her death.