A Loma Linda nursing home for children has been fined $25,000 and issued the state's most severe citation after machines failed to alert staff that a patient had stopped breathing, officials said Tuesday.
The patient was pale and cold when a staffer at Mountain View Child Care Circlebrook walked in to change his diaper early on the morning of Aug. 23, 2004, according to a state Department of Health Services report. Staffers were unable to immediately find a key to access equipment to revive the patient, the report said.
The patient, who was not identified by the state, died of a heart attack related to obstructive sleep apnea. Staff members did not know how to call for emergency help when a patient was nonresponsive or in respiratory distress, the report said.
It appeared that someone had "squished" and bent the connecting cable pins on the patient's sleep apnea monitor, which could have caused the alarm to fail, the report said, quoting a respiratory care therapist employed by the machine's manufacturer.
In its correction plan filed with the state, the nursing home said it ensures that respiratory monitors are functioning normally during every shift and that emergency equipment is easily accessible.
The fine levied was the maximum allowed under state law for a children's nursing home, said Norma Arceo, a spokeswoman for the California Department of Health Services.
Mountain View administrators could not be reached for comment Tuesday.
Also this week, an El Cajon nursing facility was fined $90,000 after an 80-year-old man accidentally set himself on fire Feb. 22 with a lighter given to him by another patient, according to the state report.
Witnesses said that the man, who liked to smoke and was on the facility's smokers patio, lit a piece of paper on his lap. The fire spread to the edges of the diaper that stuck out of his sweatpants, the report said.
The man, a resident of the Villa Las Palmas Healthcare Center, suffered second- and third-degree burns on his face and chest. He died 10 days later at a hospital.
The state concluded that the facility "failed to provide adequate supervision of designated smoking areas to ensure resident safety."
"We see this as a tragic event," said Gavin Brown, administrator of the 151-bed facility. "We lost our resident and friend of five years.
"There's a sensitive balance between respecting a resident's freedoms, preferences, dignity and quality of life and the results of restricting them due to the resident's condition or behavior," Brown said. His facility may appeal the citation, he said.
In Sacramento, the Applewood Care Center was fined $100,000 by the state after an 84-year-old woman was found in an overturned wheelchair at the bottom of a dark concrete stairway.
The woman, who suffered from dementia, was found with a crushed skull, scrapes to her face, shoulder and knees, with fractures to her ribs and wrist. She died Sept. 4, 2005, nearly four hours after arriving at an emergency room, according to the state report.
The woman's death was "avoidable," and the center failed to adequately supervise her, given her history of wandering around the facility, the report said. The center also failed to ensure that an emergency door alarm was turned on.
The facility has since replaced the alarm system and has a plan to monitor patients' whereabouts, the report said.
Applewood officials could not be reached for comment Tuesday.
In all three cases, the state Department of Health Services issued "AA" citations, the most severe, and required that each nursing home develop a correction plan.