California Healthline Highlights Recent DHS Citations
Applewood Care Center received a Class AA citation -- the most severe issued by DHS -- and a $100,000 fine after an 84-year-old woman with dementia fell down concrete steps while strapped into her wheelchair, the Sacramento Bee reports.
According to DHS, the skilled nursing facility "failed to ensure she received adequate supervision to prevent her fatal accident." The woman had a history of wandering, according to the DHS report. In addition, a lawyer for the center said no emergency alarm sounded when the patient wheeled herself out the door because an unknown person had disabled the alarm.
Applewood administrator Bill Drennan said the center has submitted a plan for improvement. A new alarm system also has been installed that allows for fewer overrides (Weaver Teichert, Sacramento Bee, 7/14).
Rimrock Villa Convalescent Hospital received a Class AA citation and a $65,000 fine after an 83-year-old woman choked to death on a sandwich she was given as a snack, the Los Angeles Times reports.
DHS found that the hospital did not follow doctor's orders to keep the patient, who had a history of choking, upright while eating and to remind her to take small bites and drink between bites.
According to DHS, "there was no evidence that the facility developed a plan of care that addressed the patient's choking."
The attorney general's office will investigate possible violations of elder-abuse laws, a spokesperson said (Lin, Los Angeles Times, 7/15).
DHS ordered Community Medical Centers to revise its records policies after a medical records mix up at University Medical Center led to the improper removal of a patient's kidney, the Fresno Bee reports.
In April, two patients had abdominal CT scans at about the same time. A radiology worker noticed that a medical file showing a mass about the size of a grapefruit above a kidney was assigned to the wrong medical file. The workers corrected the problem on one machine but did not correct it throughout the system.
Doctors who assisted in the operation said questions were raised about the procedure when they could not locate the mass, but they decided to remove the kidney anyway because it was "not normal anatomically," according to assisting surgeon Steven Parks.
The state found that the "hospital failed to ensure that radiology policies and procedures were developed and implemented" for the image system.
CMC officials said they have put in place a new system that contains more checks and balances to ensure mistakes are corrected throughout the system (Correa, Fresno Bee, 7/16).