Resident Dies from Burn Injuries Suffered at a California Nursing Facility

On March 31, 2008, a 74 year-old female resident of the Lemon Grove Care and Rehabilitation Center near San Diego, California caught fire while smoking at the gazebo area of the facility. Ten days later, the woman died of second and third degree burns she suffered to her face, head, chest, hands, and arms.

According to an investigative report by the California Department of Public Health, the woman had been with two other residents that day, smoking in an area the center had designated for smoking. The report alleged that staff members were not supervising these residents. Sitting on her electric scooter, the woman had been trying to light her cigarette, while placing her jacket over her head to block the wind. As she did so, her jacket caught on fire.


Lemon Grove Care and Rehabilitation Center
Lemon Grove is a skilled nursing facility with 158 beds, located in San Diego County. It provides a full range of nursing services, including physical, occupational, speech, and intravenous therapies. The facility helps patients recover from serious illnesses, such as stroke and pneumonia, and other major injuries. It provides these services for residents who need either long term or short-term care.

Before this recent tragedy, Lemon Grove had minor citations, one in 2005 and two in 2008. However, because the present incident resulted in a resident’s death, the California Department of Public Health issued an “AA” citation. In its report, the Department cited the center for violating 42 CFR 483.25(h)(2) of the Federal Code.

Quality of Care Nursing Residents Must Receive
Subsection 483.25 of the Federal Code designates the quality of care residents must receive to ensure residents have the highest practicable physical, mental, and psychosocial well-being. Specifically, 42 CFR 483.25, subsection (h) states, “The facility must ensure that (1) the resident environment remains as free of accident hazards as is possible; and (2) each resident receives adequate supervision and assistance devices to prevent accidents.”

“AA” Citation is the Most Severe Citation for Nursing Facilities
As a result of the “AA” citation, the center was fined $80,000 by the Department of Public Health. “AA” citations are the most serious violations a facility can receive under state law. They are issued when a resident has died at the facility and the facility’s conduct was the direct cause of the death. These citations can result in fines ranging from $25,000 to $100,000. If a facility receives two “AA” citations in less than two years, the Department of Public Health automatically starts the revocation process of a facility’s license.

In addition to “AA” citations, the Department can issue “A” citations when the facility’s violations create imminent danger or the likelihood of death or serious harm to patients. These fines range from $2,000 to $20,000. A lesser citation are “B” citations, which are issued for violations that have a direct connection to health, safety, or security, but do not meet the level of “A” or “AA” citations.

If you know of someone who is not being properly cared for at a nursing facility, it is important that you contact a nursing home abuse lawyer in California to protect his or her rights. If you have a question or comment, please respond to this posting, but please remember that your responses will not be confidential. You can also call or e-mail, if you would like to discuss the matter in confidence. Thank you for reading our blog.

California Department of Public Health Fines Nursing Homes

The California Department of Public Health (CDPH) issued citations and fines to several nursing homes in April 2008. Nursing homes licensed by California are subject to citations and fines for poor or negligent care. Citations and the fines issued by the CDPH are categorized by class, with Class AA being the most severe. The classes break down in the following manner:

• Class AA: $25,000 to $100,000 fine
• Class A: $2,000 to $20,000 fine
• Class B: $100 to $1,000 fine

The significance and severity of the violation determines the citation class and the amount of the imposed fine. Although several facilities were issued citations, the following three are examples of the most egregious.

Palm Terrace Healthcare and Rehabilitation Center
The Palm Terrace Healthcare and Rehabilitation Center in Laguna Hills was fined $75,000 for actions relating to the death of a resident. Despite observing the resident to be tired and lethargic, the staff allowed her to eat alone in her room. The resident choked on a piece of meat; she was hospitalized and died three days later. At the hospital, it was discovered that the patient had overdosed on morphine despite the lack of a prescription from her physician. The autopsy revealed that there were very high levels of morphine in her blood, and the coroner concluded that she had been dosed over a period of time prior to the choking. The coroner also concluded that there was a high probability that the morphine played a role in her choking. The police homicide office investigated the incident and could not determine who had administered the morphine to the patient. The CDPH determined that Palm Terrace failed to identify the patient’s care needs which resulted in the resident’s death and issued a Class AA citation.

The Springs at the Carlotta in Palm Desert
The Springs at the Carlotta in Palm Desert was fined $100,000 by the California Department of Public Health (CDPH). The Springs was also issued an “AA” citation. The CDPH concluded, after an investigation, that inadequate care led to the death of an 87-year-old resident in June of 2006. It concluded that the Springs failed to “identify the care needs” of the patient “based on an initial and continuing assessment.” This failure by the nursing home “presented an imminent danger” to the patient “and was the direct and proximate cause of death.” The resident had been admitted with a diagnosis of potential constipation (among other things). The facility was supposed to monitor and record the resident's bowel movements. The facility failed to properly monitor the bowel movements. After several days, the resident was vomiting and her abdomen was distended. She was transferred to a hospital where she died that same day of “Acute Peritonitis due to perforated colon due to severe constipation.”

Marysville Care Center
The Marysville Care Center in Yuba City was issued a Class AA citation and a $100,000 fine relating to the death of an 84 year old resident. She had been diagnosed with osteoarthritis, psychosis, and Alzheimer's disease and was totally dependent on the facility for her daily living needs. The CDPH reported that the facility failed to keep the resident “free from accident hazards” by not to putting down the side rails on the resident's bed. These side rails were to be used only when the resident was being turned. The report also indicated that the facility did not use a bed alarm that would notify staff if the resident attempted to get out of bed. The resident was found with her chin resting on the lower part of the bed rail with her feet on the floor. Her head was stuck between the bed rail and the bed. She was unable to free herself and choked to death.

Neglect and Elder Abuse
These three incidents of neglect are all examples of elder abuse. When visiting a loved one at a nursing home, be on the lookout for signs of neglect such as poor hygiene, dirty fingernails, signs of feces or smells of urine, unexplained weight loss, and bedsores. Facilities with staffing problems are especially prone to neglect. Staffing problems lead to high staff turnover and inadequately trained or inexperienced staff.

Thanks for reading. If you have a question or comment, feel free to reply to this posting, or send me an e-mail. If you suspect a nursing home's negligence or neglect has resulted in the injury or death of a loved one, contact me for help and immediate assistance.