Motion Picture & Television Hospital D/P SNF
23388 Mulholland Dr., Woodland Hills, CA 91364
Citation Number: 930008531
Citation Date: 12/29/2011
Violation Date: 10/17/2010
Class: AA
Penalty: $ 80,000

On 10/24/2010, a 90-year old resident with dementia died after sustaining fatal neck and spine injuries in a fall one week earlier on 10/17/2010. The facility reported that the resident, who had recently been moved to the 2nd floor, fell after wheeling herself into the stairwell. She and her wheelchair were found in the stairwell, where she complained of head, neck and back pain. She was hospitalized, where scans found that she suffered a burst fracture of her neck and spine. According to her death certificate, the cause of death was "Sequelae of Fall." The resident suffered 8 falls in a three-year period at the facility, including a fall down the same flight of stairs in 2007 and another fall three days prior to the fall that led to her death. During the investigation, the facility stated its care plan for the resident did not address her wandering behavior or wheelchair alarm use and that its staff did not document concerns about her anxiety on the day of the fall and other factors that may have contributed to the fall. The facility was cited because it failed to provide a safe environment and adequate supervision to the resident. Which resulted in her death.