In Brief: CDPH Fines Kindred Nursing Home Facility $100,000

The CDPH found that Care Center of Rossmoor in Walnut Creek had improperly replaced a patient’s tracheostomy tube, causing air to flow underneath the patient’s skin. An investigation determined that the patient was improperly placed prior to the replacement of tube. The patient was elevated by about 30 degrees in their bed, when they should have been laying flat. The incorrectly placed tube led to oxygen deprivation in the patient, aggravated by the fact that staff failed to use an oral bag mask to try and improve oxygenation. The patient died about four hours later.

In addition to the fine, Care Center of Rossmoor was also issued a AA citation, the most severe penalty under state law.

This is not the first time the facility has drawn a fine for mishandling a patient with a tracheostomy tube. In 2013, staff failed to properly monitor a valve on the 81-year-old female patient’s tracheostomy tube. The patient died after the respiratory therapist charged with monitoring her left her room. The patient’s tracheostomy tube was fitted with a Passy Muir valve to allow exhalations out of the mouth and nose.

Care Center of Rossmoor is owned by Kindred Healthcare, which operates nursing homes and affiliated facilities nationwide.