$90,000 fine for fatal fall
San Jose Mercury News had an article about a Stockton nursing home facing California's stiffest penalty after state investigators found the facility did not adequately protect a 92-year-old resident from a fatal fall. The 120-bed Valley Gardens Health Care and Rehabilitation Center received a "AA" citation and a $90,000 fine for the 2007 death of retired Stockton businessman Robert Doscher.
A California Department of Public Health report found staff at Valley Gardens failed to check on Doscher as often as his chart recommended. The state said Doscher's death certificate listed his cause of death as accidental from falling down on his head in the bathroom.
Recordnet.com had additional information in an article. Valley Gardens failed to ensure that the 92-year-old Doscher was adequately supervised and, as a result, he fell and later died, according to Dr. Mark Horton, director of the California Department of Public Health. By its own assessment, Valley Gardens knew that Doscher was a serious risk to himself but it failed to act properly in protecting him from falling, according to the state's recently concluded investigation.
Doscher was admitted to Valley Gardens on May 18, 2007, from an acute-care hospital. He required the use of a walker when he was admitted, and it was initially planned that he could be discharged to a board-and-care facility when his condition stabilized. He was assessed by Valley Gardens nursing staff as a "high risk for falls" and his chart indicated that he should be checked every one to two hours. Also, he was to be told not to get up without assistance; a motion-monitor alarm was to be used to alert staff to any unsafe activity; and he should have been placed in front of a nursing station for closer observation.
Three days after he was admitted, he was found on the floor, where he hit his head, apparently after falling while trying to get back into bed by himself, according to the state's report. As of June 4, the report notes that "there was no documented evidence the resident was checked on every two hours" and he still was not located in front of a nursing station, as required by his assessment.
On June 12, two days before he died, he was again discovered on the floor, apparently after a fall. The report notes that "resident A rapidly developed a change in condition manifested by agitation and then a decrease in his level of consciousness." The next day, he was taken to an acute-care hospital in a comatose state, and within 24 hours he was dead.
Doscher's death certificate, according to the state, listed his cause of death as "accidental from falling down on his head in the bathroom," resulting in an acute subdural hematoma from blunt force trauma.
Valley Gardens is a for-profit skilled nursing facility owned by Kindred Healthcare Inc. of Louisville, Ky. Kindred, with revenue of more than $4 billion as of June 30, operates 222 skilled-nursing facilities and more than 650 health care programs in 41 states, according to its Web site.
Its Stockton facility has a two-star "below average" rating - out of five stars - on Medicare's Nursing Home Compare Web site, which looks at health inspections, nurse staffing and quality measures and then assigns ratings based on nationwide standards.
