CDPH Fines L.A. Nursing Home $100K

The California Department of Public Health has fined the Holiday Manor Care nursing home in Winnetka in connection with the death of a patient in 2014 records show.

According to a CDPH investigation, the unnamed patient was found dazed near her bed after an apparent fall, with a contusion on her forehead. She later succumbed to an intercranial hemorrhage at an acute care hospital about nine days after the incident.

The patient was suffering from dementia and was also being treated for a heart condition with a blood thinner, which apparently aggravated the intercranial bleeding. She had been judged to be an extremely high risk for a fall, and was to be assisted in leaving her bed at all times, according to her assessment.

However, the patient’s medical records appeared to be inconsistent as to whether she needed aid at all times, and interviews with Manor Care clinical staff suggested that at times she left her bed on her own.

The $100,000 penalty is the most that can be levied against a nursing facility. It was accompanied by a class AA citation, the most severe under state law.

In addition to paying the fine, Manor Care instituted a plan of correction that included reviewing plans of care for all patients. Staff was instructed to communicate among one another about patient status prior to shift changes.

Staff also received extensive training regarding how to better monitor and care for patients who are at risk for falls, records show.