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June 19, 2009

State Issues Two $100,000 Fines for Neglect that Causes the
Death of Encinitas and Los Angeles Nursing Home Residents

The latest in a seemingly endless series of deaths caused by nursing home neglect took the lives of two elderly residents of Encinitas and Los Angeles nursing homes. State investigations by the California Department of Public Health led to $100,000 fines in both instances. In one case, the state acted with unusual speed. The other case involved deplorable delays.

On May 13, 2009, a resident of the Aviara Healthcare Center in Encinitas died after suffering a tragic fall three days earlier. The resident had been admitted to Aviara Healthcare in late April 2009 for rehabilitation of a fractured hip and was reportedly doing well in therapy.

According to a June 9, 2009 investigation report by the Department of Public Health, the resident suffered two falls at the facility. The first fall, on May 9, 2009, occurred when he tried to get out of bed early in the morning. No injuries were reported, but the nursing staff decided that day to begin attaching a tab alarm to his bed clothes to alert the staff if he attempted to get out of bed.

The following morning, at 3 am, the resident got out of bed and walked into the hallway without response by the nursing staff. The investigation report does not reveal if the alarm sounded. As the resident entered the hallway outside his room, a nurse saw him stumble and grab on to a Hoyer lift – a large mechanical lift used to lift residents out of bed – that was stored in the corridor just outside the resident’s room. The wall in that area did not have a hand rail.

The resident fell, pulling the mechanical lift down onto the floor with him, striking his head on the metal frame of the mechanical lift. This fall caused such a severe bleed in the resident’s brain that the entire brain was pushed one third of an inch past the center point of his brain to the right side. He died three days later due to blunt force trauma to his head.

The investigation found that Aviara Healthcare’s decision to store a large piece of equipment, which is easily overturned, in the hallway led to the resident’s death. The investigator noted that seven different staff members stated the mechanical lift was supposed to be stored in the shower rooms when not in use. Notwithstanding this knowledge and notification that the mechanical lift posed a danger to residents, the facility continued to store it outside the deceased resident’s room. The investigator observed it in this location on May 13, 2009, and again on May 17, 2009, several days after the resident’s death.

The Department of Public Health issued an AA citation and $100,000 fine to Aviara Healthcare Center on June 9, 2009. The timely investigation and swift action show the Department of Public Health at its best.

The second case involves the death of an 83 year old resident of Lakewood Manor North, a skilled nursing facility in Los Angeles. On June 16, 2009, the Department of Public Health issued a press release stating it had issued an AA citation and $100,000 fine to Lakewood Manor North for failing to prevent a fall that caused a resident’s head injury and death.

The neglect took place in January 2007, about 30 months ago. It involved an 83 year old resident who was totally dependent on staff for care and needed help to get in and out of bed. He was on medications that increased the risk of bleeding.

According to the September 7, 2007, investigation report, the resident struck his head on the bedpost while two certified nursing assistants (CNAs) were helping him get out of bed at 8 am on January 4, 2007. Contrary to his care plan and facility policies, the CNAs did not hold onto the resident after sitting him up in bed, leading to the fall.

The resident sustained a hematoma (swelling containing blood) on the side of his head. Reportedly, a nurse paged the doctor, who did not respond. The doctor stated he did not recall being paged. The facility did not contact the alternate physician or the medical director when the resident’s attending physician did not respond to the page.

The resident complained of not feeling well during the day and did not eat lunch or dinner. He was put into bed in the afternoon and observed to be lethargic. His condition worsened that evening and he was transferred to the hospital at 9:30 pm, more than 13 hours after he was injured.

The hospital found that he had suffered bleeding of the brain. He died in the hospital on January 9, 2007, five days later. The death certificate stated the resident’s immediate cause of death was acute cerebellar hemorrhage and other significant conditions included head trauma.

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.

Although the Department of Public Health reports beginning the investigation on January 12, 2007, three days after the resident’s death, it delayed enforcement action until this week, 30 months later. The appalling delay largely defeats the purpose of issuing a fine. Department of Public Health investigations are supposed to protect other residents from harm, but its glacial pace in this case did little to deter further neglect over the last 2 ½ years.

CANHR is also concerned that few fines are collected. The Department of Public Health has collected less than a third of the fines it has issued to California nursing homes over the last three years.

The AA citations are posted in the newsroom of CANHR’s website:

For more information contact:
Patricia McGinnis, Executive Director, (415) 974-5171,
Michael Connors, Advocate, (626) 796-6178,

California Advocates for Nursing Home Reform (CANHR)
650 Harrison Street, 2nd Floor, San Francisco, CA 94107

Page Last Modified: June 19, 2009