Arbor View Rehabilitation and Wellness Center
1338 20th Street, Santa Monica, CA  90404
Citation Number: 910006173
Citation Date: 7/28/2009
Violation Date: 9/8/2008
Class: AA
Penalty: $ 100,000

On 10/24/08, an 88 year old resident died stemming from a licensed vocational nurse's failed reinsertion of a feeding (gastrostomy) tube that was initially inserted during a hospital stay on 8/29/08. The feeding tube became dislodged at Arbor View on September 8, 2008 and was reinserted by a licensed vocational nurse (LVN). Instead of inserting the tube into her stomach, the nurse inserted it in the resident's abdomen and continued tube feedings. After the resident started vomiting and her health condition deteriorated the next day, she was hospitalized. A scan found massive amounts of fluid in her abdomen. An autopsy determined that her death was caused by damage to her abdomen. The nurse had reinserted the feeding tube despite hospital orders stating that the radiology department should reinsert the tube if it fell out. The facility was cited because it violated its own policy that a licensed nurse can only reinsert a gastrostomy tube that had been in place for three months or more. According to a family member, the resident had been doing well prior to the neglect that caused her death.