The Applewood Care Center of Sacramento has been slapped with the most severe state citation and fined $100,000 for the death of an 84-year-old woman who fell down concrete steps while strapped in her wheelchair.
The 51-bed facility at 1090 Rio Lane was cited for failure to protect the woman whose "skull was crushed in this avoidable fall," on Sept. 4, 2005, state officials concluded.
The Class AA citation recently issued by the California Department of Health Services states that the unnamed patient wheeled herself out a side door in the dark and later was found on the asphalt driveway.
Carole Herman is founder of the Foundation Aiding the Elderly, which filed a complaint on behalf of the patient's daughter. Herman said it was the home's job to supervise the woman, who suffered from dementia and had been in the home for a year.
"She was a wanderer even though she was in a wheelchair and she was unsafe," Herman said. "She had a history of falls."
State licensing officials investigated and agreed the skilled nursing facility "failed to ensure she received adequate supervision to prevent her fatal accident."
Applewood administrator Bill Drennan said the facility has submitted a plan for improvements. He referred other questions to the home's owner, Riverside Convalescent Hospital Inc. of Chico.
"We try to give very good care," Drennan said.
Michael LeVangie, Riverside's attorney, said his client hasn't decided whether to appeal the citation or fine but that the patient's death was a tragic accident.
"The system that should have prevented this accident was in place and it failed," LeVangie said. "This was something that never should have happened."
LeVangie said the facility's owners disagree with some of the facts cited in the citation, but not the cause of death from the fall.
After the patient was discovered missing, a staff member found her at the bottom of the three concrete stairs with her wheelchair on top of her. She suffered fractures of two ribs, the left clavicle and right wrist; a skull fracture; and hematoma of her brain.
A breathing tube was inserted en route to the hospital, but she died three hours and 48 minutes later. The pathology report from the Sacramento County Coroner's Office ruled her death an accident.
The state citation issued last week cited medical records documenting the patient's "inappropriate judgment and wandering." But the citation said her records included "no documented plan regarding how the facility would provide supervision for the resident's wandering."
LeVangie said no emergency alarm sounded when the patient propelled herself out the door because some unknown person had reached above the door and turned off the alarm.
A new alarm system has been installed that allows fewer overrides, he said.
Although state officials did not cite the facility for inadequate staffing, the report mentioned that a certified nurse assistant had failed to report for duty that evening.