Lakewood Manor North
831 S Lake Street, Los Angeles,  90057
Citation Number: 970005303
Citation Date: 6/4/2009
Violation Date: 1/5/2007
Class: AA
Penalty: $ 100,000

On 1/9/07, an 83 year old resident died after striking his head on the bedpost four days earlier while two certified nursing assistants (CNAs) were helping him get out of bed in the morning. Contrary to his careplan, the CNAs didn't hold onto the resident after sitting him up in bed, leading to the fall. He sustained a hematoma (swelling containing blood) on the side of his head. At the time of the injury, the facility paged the doctor, who did not respond. The resident reported not feeling well later in the day, was put to bed in the afternoon and did not eat lunch or dinner. His condition worsened that evening and he was taken to the hospital, where it was found that he had suffered bleeding of the brain. He died in the hospital from this condition four days later. The facility was cited because it failed to provide adequate support while transferring the resident from bed, failed to conduct an ongoing assessment of the resident's head injury, failed to immediately consult with his physician, and failed to call 911 in accordance with its policy on emergencies. These failures led to the resident's death.