Facility Is Fined in Boy’s Death

A skilled-nursing home at the Tustin Hospital and Medical Center has been fined $90,000 and given the state’s most severe citation in the death last spring of a 7-year-old boy, state officials said Monday.

“This is not common,” Ken August, a spokesman for the California Department of Health Services, said of the AA citation issued to the medical center’s skilled-nursing facility. “It’s cited only when a facility, through its action or inaction, causes the death of a resident.”

In addition to the fine, he said, the facility was required to submit a detailed plan to the state outlining steps it had taken or planned to take to ensure that such an incident would not recur. August said the plan has been submitted and approved.

The hospital declined to respond Monday to several requests for comment.

According to August, the violation occurred June 5 when the 7-year-old, who had been admitted to the facility 18 months earlier with a traumatic brain injury and seizure disorder, underwent a breathing treatment administered by a respiratory therapist via the patient’s tracheostomy, an incision in his upper chest allowing him to breathe.

For unknown reasons and in violation of the facility’s policy, August said, the therapist left the child, whose name has not been released, unattended for about 10 minutes. When he returned, the spokesman said, the therapist found the breathing apparatus disconnected and the patient dead.

“The coroner was called, and it was determined that the cause of death was respiratory failure,” August said. “We were not able to determine how the respirator became unattached.”

The investigation included a review of medical records and interviews with staff, August said.

“The facility’s policy and procedure directs the respiratory therapist to stay with the resident during the treatment,” the health department’s press release said.

August said he did not know whether the respiratory therapist involved had been fired or what other steps the hospital had taken to correct the situation.

The state issues about a dozen AA citations a year, he said; any facility receiving three or more in a 12-month period is in danger of losing its certification. He said he was unaware of the Tustin facility having received any previous AA citations.

According to a recent report issued by the federal government, which also inspects and rates nursing-care homes, the Tustin facility was cited for 10 deficiencies -- slightly fewer than the state average, but more than the national average -- during the 15-month period ending Aug. 31.

Although all the citations were relatively minor, one of them did indicate that inspectors had determined that the facility failed to “properly care for residents needing special services, including ... tracheostomy care, tracheal suctioning” and “respiratory care.”