Local Care Center Cited, Fined in Patient's Choking Death

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    NEWSLETTERS

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    The Villa Rancho Bernardo Care Center on Bernardo Center Drive.

    A local care center has been cited and fined by the California Department of Public Health (CDPH) after an investigation determined that inadequate care resulted in the death of a resident.

    According to the CDPH, Villa Rancho Bernardo Care Center in San Diego has received a Class “AA” citation, the most severe penalty under state law, and a fine of $100,000 from the State of California.

    The investigation report says the care center failed to follow physician’s orders for a 61-year-old patient with dementia who required a special chopped diet.

    The patient’s food needed to be cut into small pieces every day, but the report says care center staffers failed to do so one day, serving the patient two pancakes and two uncut sausages.

    As a result, the patient put all four food items into his mouth, choked and died at the center, the report states. Read the full report here.

    The CDHP says the citation process is part of the Department’s ongoing enforcement efforts to protect the health and safety of patients and improve the quality of care provided to residents in nursing facilities.

    This isn’t first time the CDHP has cited and fined the Villa Rancho Bernardo Care Center.

    According to a separate investigation report filed in February 2010, the care facility received another Class “AA” citation and $100,000 fine for the November 2009 death of a patient with dementia and psychosis.

    That report says the resident sustained fatal head injuries after falling down a concrete stairwell outside the care center, and died two days later.

    The report says the resident – who was in a wheelchair – opened an alarmed emergency door and then fell down 20 concrete steps while still restrained in his wheelchair. He was unsupervised at the time of the fall.

    The report says staffers at the facility “failed to supervise the resident despite a history of wandering and exit seeking behaviors, and despite the resident's care plan calling for staff to keep the resident in an observed area.”

    The resident had tried to exit the same door earlier the same day, the report states. The care center was cited and fined for factors leading to the resident’s death.

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