Northern California nursing home is fined $100,000 over patient’s death


A Northern California nursing home has been fined $100,000 after its staff allegedly failed to prevent a patient from falling twice and suffering a fatal head injury for which he was not treated, state public health officials announced recently.

The 85-year-old patient, who had a heart condition and diabetes, was supposed to use a walker and be supervised when walking, according to a state investigator’s report released Aug. 3 on Pilgrim Haven Health Facility in Los Altos.

But a state investigator found Pilgrim Haven staff members failed to install an electronic fall monitor as ordered by the patient’s doctor and also failed to ensure that the patient’s walker was within reach. On Oct. 3, staff members discovered the man sitting on the floor of his room, having fallen and scratched his head, according to a fax sent to his doctor.

“Sometimes he doesn’t use his walker, which is dangerous for him,” an unidentified Pilgrim Haven employee wrote.

On Dec. 7, staff members found the man collapsed on the floor of his room, away from his walker, where he told them he had fallen, according to staff notes reviewed by the state investigator.

The man denied that he had hit his head and he was given a neurological evaluation that appeared normal, according to staff members’ notes. However, when he turned pale and listless and started vomiting later that night, staff members did not assess him for possible head injuries or notify his doctor for about two hours, in part because there was no registered nurse on duty that night, according to the patient’s medical records.

After staff members notified the patient’s nephew and doctor, they had the man transferred to a hospital, where he died the next morning. Doctors used a CT scan to determine that the cause of death was bleeding in the brain and a fall with head trauma, according to medical records cited in the investigator’s report.

Pilgrim Haven is one of 11 nursing homes owned by the nonprofit American Baptist Homes of the West. The facility where the 85-year-old was treated houses about 50 to 60 people on a given day, according to Rae Holt, Pilgrim Haven’s executive director.

In a plan of correction submitted to the state, nursing home officials said they had checked to ensure electronic fall prevention devices were in place for other residents and that they reviewed fall prevention policies with the facility’s licensed nurses in May.

Holt said the nursing home is appealing the state citation.

“We disagree with the findings,” Holt said. “We feel that we responded appropriately and complied with regulations.”

He said the nursing home had never been cited by state regulators before and received a superior rating during its last state inspection. Department of Public Health records, which are available only as of 2004, show the facility had not been previously cited.