MANORCARE HEALTH SERVICES-HEMET
1717 WEST STETSON AVENUE, HEMET, CA 92545
Citation Number: 250003781
Citation Date: 3/13/2007
Violation Date: 1/6/2006
Class: AA
Penalty: $ 75000.00

On 1/6/06, an 83-year-old resident fell from his wheelchair, striking his head, causing a closed head injury and internal bleeding around the brain. He was hospitalized and died a week later on 1/13/06 after life support was removed. The resident had a diagnosis of Alzheimer's Disease and was almost totally dependent on the facility for care. He required a safety device, a lap buddy, when in the wheelchair, to prevent falls. The facility was cited because its staff observed that the physician-ordered lap buddy was not in place and failed to protect the resident from falling, which resulted in his death.