Convalescent Center, Mission Street
5767 Mission Street, San Francisco, CA 94112
Citation Number: 220007568
Citation Date: 09/14/2010
Violation Date: 3/22/2010
Class: AA
Penalty: $ 100,000

On his first day of work on 3/22/10, a certified nursing assistant (CNA) killed an elderly resident who suffered from dementia when he pinched her nose and used a pillow to smother her. After a staff member caught him in the act, the perpetrator fled the building and was later apprehended by police. A housekeeper observed the perpetrator in the victim's room with a pillow over her face a few minutes before she was killed, but left when the perpetrator told her to get out of the room. Prior to the homicide, another CNA asked the director of nursing (DON) "at least 3 times" to check on the perpetrator after observing him acting in a confused and disoriented manner. Another employee reported he thought the perpetrator was on drugs. Each time they complained, the DON said it was okay and never checked on the perpetrator. The CNA who expressed concerns said that within 30 minutes of conversing with the DON, the resident was dead. The perpetrator was assigned to care for 7 residents alone with no direct supervision that morning despite it being his first day of work and his total lack of any experience in caring for the elderly. The licensed nurse who was supposed to supervise the perpetrator said he did not give the perpetrator any information on the residents he was supposed to care for and the nurse did not know what the perpetrator was doing prior to the deadly assault. The Medical Examiner ruled that the resident's death was a homicide due to traumatic injuries caused by smothering, strangulation and blunt force. The facility was cited because its failure to protect the resident from physical abuse caused her death.