On October 7, the California Department of Public Health (CDPH) announced that it had levied an ‘AA Citation,’ its most severe penalty under law, and a $90,000 fine to Fallbrook Hospital’s Skilled Nursing Facility, after finishing an investigation in which they concluded that inadequate care led to the death of a male patient.
“The ceiling for a fine in this case is $100,000 and they were issued one for $90,000” said Ralph Montano, public affairs spokesperson for the CDPH. “Our attorneys base that on a lot of criteria they review.” State citations that require a civil monetary penalty be imposed are categorized as Class B, A or AA. The associated fines range from $100 to $1,000 for Class B; $2,000 to $20,000 for Class A; and $25,000 to $100,000 for Class AA. The citation class and amount of the fine depend upon the significance and severity of the substantiated violation, as prescribed and defined in California law.
In the report prepared by the CDPH, it was stated that the nursing home had assessed the patient to be at high risk for falls when he was admitted to the facility last summer. Written protocol at the facility for individuals at high risk of falls such as this includes equipping the patient with a clip alarm, pressure sensitive alarm, bed in a low position and putting a mattress on the floor.
One nurse said she had instructed the certified nursing assistants (CNAs) to “institute the fall precautions before the patient even arrived at the facility, because she knew he was a high risk,” the report stated. The nurse also told investigators that she “had not followed up with the CNAs to ensure they had implemented the appropriate fall interventions.”
The report said when the man’s roommate heard the man fall out of bed onto the floor he came out into the hallway and notified nurses.
One of the nurses said she saw the resident “lying on the floor, on his left side, toward the bottom of his bed.” Also in the report, one CNS said the man’s bed was in the low position, “but there was no mattress on the floor and no alarms,” adding that the bed alarms and mattress were not instituted until after the resident’s fall. The report states that the man was in pain immediately after the fall and had suffered an intertrochanteric fracture of the left femur, which required surgery. The patient died five days after the fall due to complications, authorities said.
In this case, Dr. Mark Horton, director of CDPH said, “The facility failed to implement a plan of care to prevent a resident’s injury. A fall resulted in complications that led to the death of the resident.”
“The violation of these regulations presented an imminent danger to the resident and was a direct proximate cause of the death of the resident,” the report stated.
Monique Murphy-Mijares, spokesperson for Fallbrook Hospital, said, “Fallbrook Skilled Nursing Facility submitted and implemented a plan of correction The Skilled Nursing Facility was re-surveyed and deemed substantially compliant, and there was no interruption in services.”
Horton reiterated that all nursing facilities in California are required to be in compliance with applicable state and federal laws and regulations governing health care facilities. “Facilities are required to comply with these standards to ensure quality of care,” he said. “California has the statutory authority to impose fines against nursing facilities it licenses as part of enforcement remedies for poor care.”
Of Fallbrook Hospital’s Skilled Nursing Facility, Murphy-Mijares said, “The caregivers at the facility are dedicated to providing the highest level of skilled and compassionate nursing care, round-the-clock for individuals needing nursing and specialty medical care following hospitalization for an illness, accident or surgery.
Operated for the last eleven years by Community Health Systems (CHS), the skilled nursing facility has 99 beds and provides both short- and long-term care.