Pilgrim Haven Health Facility
373 Pine Lane, Los Altos, CA 94022
Citation Number: 220007186
Citation Date: 05/26/2010
Violation Date: 12/7/2009
Class: AA
Penalty: $ 100,000

An 85 year old resident, who had a history of falling, fell on 12/7/09, suffered a fatal head injury and died the next day. At 11 am, the resident was found on the floor next to his bed, with his walker in the middle of the room. He turned pale and started vomiting at 7:30 pm that evening. His physician wasn't notified until 2 hours later after he became unresponsive. There was only one licensed nurse working that evening, and there wasn't an RN on duty to ensure consistent monitoring and accurate assessment of the resident's change of condition after his fall. He was finally sent to the hospital at 11:30 pm, where it was determined that he had suffered a traumatic subdural hematoma, which caused his death. The facility's failure to monitor and supervise the resident prior to the fall and its failure to properly assess and respond to his injuries afterward led to his death.