Beleaguered Veterans Home Fined $64,500 in 3 Deaths

The embattled California Veterans Home in Barstow was fined an extraordinary $64,500 Friday in the deaths of three patients, an action that puts its license in new jeopardy.

Diana M. Bonta, state director of health services, also referred the veterans’ deaths to state and local prosecutors.

The state-run nursing home for aging and disabled military veterans barely kept its license earlier this year after a seven-month investigation.

Citing a wide range of violations of state and federal law, the Department of Health Services issued an unprecedented six major citations. The total of $64,500 in fines against the nursing home in San Bernardino County was also a record.

In a statement, health department officials said the home did not pay close enough attention to patient Paul Stevens, 76, a World War II Army sergeant, who died Feb. 11. The coroner and a treating physician at the home said Stevens died choking on broccoli. Officials of the veterans home said he died of a heart attack.

Health department officials charged that Stevens, whose case was not reported as an unusual death, was not given adequate assistance in cutting his food despite limited use of his hands, worsening eyesight and his refusal to wear dentures.

In another case, which the department announced for the first time Friday, an unidentified patient died in a diabetic coma of a skyrocketing blood sugar level that had not been called to a physician’s attention.

The third death, also disclosed for the first time, involved an unidentified patient who received the sedative phenobarbital “twice daily for 70 consecutive days without a physician’s order.”

The fines were the maximum allowed and are subject to appeal by the Department of Veterans Affairs, parent agency of the home.

Combined, the violations, two of which are known as “Double A” citations, the most serious the health department can issue, put the Barstow home’s license in jeopardy again, officials said.

“In order to get a Double A, the violations [must] result in the direct proximate cause of a resident’s death. So, what they did or did not do caused someone’s death,” said Brenda Klutz, deputy director of licensing and certification.

She said only about 25 such citations are issued to the thousands of nursing homes statewide every year.

She said, however, that patients at the home would not be moved immediately. She said it could take up to a year before the appeals process is completed and a decision on revoking the license is made.

Klutz said the three death cases were sent to the state attorney general and the San Bernardino County district attorney for investigation of potential elder abuse. She said the law requires reporting cases when department investigators suspect a crime has been committed, much as teachers and physicians must report suspected child abuse.

Gerald Rucker, undersecretary of veterans affairs, said he expects appeals. “We will do a thorough evaluation and determine whether there is a reasonable reason to dispute them. We’ll also immediately create a correction plan of action so this won’t happen again, if, indeed, it occurred as reported,” he said.

The Barstow home also was cited for allegedly retaliating against one of its attending physicians, Dr. Liem C. Vu, who cooperated with the San Bernardino County coroner in reaching the conclusion that Stevens choked to death rather than died of a heart attack, as the home insisted.

Vu was placed on administrative leave March 28, allegedly for reasons unrelated to the Stevens case. Later, the facility “retaliated against the physician by firing him within 120 days of his cooperation with the coroner’s office,” the health department said.

“This [Stevens] case was not mentioned at all in his dismissal,” Rucker said of Vu’s firing. “It was for other medical practices.”

In another violation, the department said a nurse at the scene of Stevens’ collapse failed to record in her medical notes that broccoli was found in his mouth. The department said this, together with interviews and other records, suggests that the home “willfully failed to accurately record the actual care and services provided [to Stevens] on the day of his death.”