2 Rest Homes Are Cited in Deaths of Patients

The state Department of Health Services on Friday issued its most serious type of citations and fines to two Southern California nursing homes after determining that substandard care led to two patient deaths.

The state fined Brighton Gardens of Camarillo $60,000 in a case in which an 84-year-old woman died after falling and hitting her head as two nursing assistants attempted to transfer her from a wheelchair to her bed.

The facility also received an “AA” citation in connection with the November 2000 case, the most severe under state law, state Health Director Diana M. Bonta said in a statement.

In addition, Good Shepherd Care Center on Kagel Canyon Road in Lakeview Terrace was fined $100,000 in the case of a 73-year-old woman who smoked in bed, set fire to the bed clothes and ultimately died of her injuries.

BJay Hartz, attorney for Good Shepherd, said he just received the citation late Friday and has not had time to review it. Brighton Gardens administrators did not return a telephone call for comment Friday.

In both cases, state inspectors found that the patients’ physical condition and psychological histories warranted special care and monitoring by the staff.

At Brighton Gardens, the nursing home’s records showed that the patient needed special attention while being moved. She suffered from impaired vision, balance and behavioral problems, and was at a high risk for falls.

The state concluded that two nursing assistants used an unsafe and unapproved transfer technique while moving the woman from a wheelchair to her bed. The resident fell and struck her head while being moved. She died about eight hours later.

A coroner’s report attributed the cause of death to a blunt force head injury.

The state’s investigation found that Brighton Gardens failed to impose procedures specifying the proper techniques and equipment that staff is supposed to use to ensure patients are safely moved in such instances. The probe included a review of medical records and interviews with employees.

The woman who died at Good Shepherd after setting her bed on fire had been diagnosed with bipolar disorder, depression and altered mental states, along with other medical conditions. She was a chronic smoker who previously had not complied with the facility’s regulations, and the staff should have monitored her to ensure she did not smoke in her room, the citation states.

Both facilities must immediately develop plans to prevent such lapses, but do not have to pay the fines until any appeals have been adjudicated.