Veterans Home Fined in Man’s Death

The state-run veterans home at Barstow was fined a record $100,000 Friday in the death of an 80-year-old former serviceman whose deteriorating health was not reported to his physician by the nursing staff, officials announced.

News of the fine and the previously undisclosed death came a day after a surprise decision by other state officials to close the skilled nursing ward of the High Desert facility and move about 85 residents to state veterans homes at Chula Vista and Yountville.

The fine, the maximum that can be levied by the state Department of Health Services, comes two months after the facility was penalized $95,000 in connection with another patient’s death because of poor care.

Leah Brooks, department spokeswoman, said the fines are the two highest ever levied against any government or private nursing home in California. The latest sanction raised the level of fines against the Barstow home to more than $260,000 over the last few years. The facility has been open since 1996.

The death of the serviceman Jan. 9 was an “example of the continuing problems that we have had to deal with at Barstow,” said a spokesman for Secretary of Veterans Affairs Maurice K. Johannessen, who ordered the nursing facility to be closed. The order does not affect Barstow housing units for about 220 able-bodied and semi-independent veterans who need help with everyday tasks but not medical attention.

Johannessen said Thursday that he acted to cut the state’s losses at Barstow, where heavy fines have been imposed in at least four deaths in the last four years. Additionally, the facility lost its license temporarily and suffered other sanctions resulting from poor patient care.

Veterans Affairs spokesman Andrew Kotch said Friday that department lawyers would review the most recent citation before a decision is made on whether to appeal.

The San Bernardino County coroner’s office identified the patient who prompted Friday’s fine as Otho Lee Duckwiler, who served in the Korean War era in the Army and Navy. He had lived at the veterans home since October but suffered from an array of illnesses, including diabetes, pulmonary disease, anemia and degenerating joints.

Coroner’s spokesman Robert Shaw said Duckwiler’s cause of death was a heart attack during emergency surgery at Barstow Community Hospital, where he had been taken after having abdominal pain.

Department of Health Services investigators reported that nurses at the home failed to adequately monitor Duckwiler and report his deteriorating condition. At the time, Duckwiler was being fed through a tube.

He vomited Jan. 7 and Jan. 8, investigators found. The first incident was reported to his doctor by the nursing staff, but the second incident was not. A social worker told the physician Jan. 9 that Duckwiler “did not look good.” The doctor examined him and ordered that he be taken to the community hospital.

During surgery, officials said, they discovered a chronic problem in his small intestine had worsened, turned gangrenous and become infected, poisoning his bloodstream. He suffered a fatal heart attack during the operation.