State Fines Care Home After Death

An Ontario nursing home was fined $50,000 and cited Thursday by state regulators after an 88-year-old woman died there after workers allegedly failed to perform mouth-to-mouth resuscitation when they found she had stopped breathing.

The complaint, known as an AA citation, is the most severe penalty issued by the state Department of Health Services. In 2004, the agency issued 14 such citations in the state.

A spokesman for the Inland Christian Home, where the woman died in January 2004, said the facility planned to appeal, arguing that the actions of the workers did not lead to the death.

“We don’t agree with the state that our actions caused this death,” said administrator Dave Stienstra, who declined to discuss details of the case. He added that the nursing home had a good record overall.

State officials said the same home was issued another AA citation in 1991. Details of that violation were not available Thursday. AA citations typically result from the death of a patient when the facility is at fault, according to state officials.

The nursing home, run by a nonprofit foundation, provides around-the-clock care and medical assistance to 230 elderly residents. In addition to the citation, the department issued a plan outlining how Inland Christian Home could avoid such problems.

According to state records, the woman -- identified by the San Bernardino County coroner as Pauline Prole of Chino -- was admitted to the home in June 2003. She had a brain tumor, dementia, pneumonia and a urinary tract infection, the records show.

On Jan. 7, 2004, a nursing assistant checked on Prole and found she was not breathing and had no pulse but was warm to the touch, according to a state report on the case. The nurse in charge, a licensed vocational nurse whose name was not included in the report, tried two or three times to blow air into the woman’s lungs, using the mask from a ventilation bag.

When the nurse left to call paramedics, two nursing assistants performed heart compressions on the woman but did not try mouth-to-mouth, according to the state report. When paramedics arrived, they tried chest compressions and blowing air into her lungs, the report said. Prole was pronounced dead at Chino Valley Medical Center a few hours later.

One of the paramedics told state investigators that the nursing staff said they didn’t try to breathe air into the woman’s lungs because they couldn’t find the mask for the ventilation bag, according to the state report.

Prole’s daughter had signed a document requiring the nursing home staff to perform cardiopulmonary resuscitation if Prole was unable to breathe on her own, according to state records.

Prole’s family could not be reached for comment Thursday.

The report said the nursing assistants’ failure to perform mouth-to-mouth led to Prole’s death and violated the nursing home’s policies.

The report said the failure “presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and was a direct proximate cause of death.”

The coroner ruled Prole’s cause of death as “respiratory arrest” due to “anemia or chronic disease.”

Also Thursday, a Tenet-owned skilled nursing facility in Santa Ana was fined $75,000 and received an AA citation after a 45-year-old mentally disabled man died when a respiratory therapist botched the replacement of a tracheotomy tube, according to the state Department of Health Services.

The patient died July 30 at Coast Communities Hospital.

The investigation found that Coastal Communities Hospital did not have a plan for addressing difficult tracheotomy tube changes nor did it follow procedures for the changes, causing the man’s death.