An elderly resident fell 24 times in a year. His Sacramento care facility faces $10,000 fine
Nelson's doctor prescribed the placement of alarms on his wheelchair and bed to alert staff at the facility when he was up and to reduce the potential for a fall. But no alarms had been installed, even though the family asked for them repeatedly.
So during that visit in August,
Just hours after the meeting,
"Four hours later, there was a message on my phone saying Alan had had a really bad fall," Alexander said. "And that's in the death certificate -- the injury (from) that fall, to Alan's skull and brain -- is listed as one of the contributing causes of his death."
He suffered fractures to his left frontal skull and left nasal bone and had a brain bleed, according to state documents.
Nelson died, at the age of 76, five weeks later.
Angered by the care his stepfather had received at the facility,
"There were a number of falls (
An investigation by the
Ultimately, the state decided to issue an enhanced penalty of
"Carlton Senior Living has been providing seniors with high quality care in a home like environment for more than 30 years," the statement reads. "We are committed to protecting residents' privacy and as such cannot comment on a particular resident's care. We value our relationship with the
According to the department's website, Carlton Senior Living, formerly
The majority of the Type A and B citations issued by the state are the result of investigations conducted in response to complaints.
Described as an athletic person by his wife, Dr.
After he was diagnosed with Parkinson's disease and dementia, his wife determined she could no longer provide her husband with the care he needed, and she thought
The assisted living facility is off
Over the course of his stay there,
"He seemed to be all right, he had friends there and there were things for him to do," Alexander-Nelson said. "He did what he thought -- that I thought -- was the best."
At home,
"They had rules that I didn't understand," Alexander-Nelson said. "But they were supposed to take care of him carefully and we paid a lot of extra money for that."
As Nelson's care became more advanced, the financial cost to his family increased. Generally, long-term insurance provided around
Documents both obtained by The Bee and posted online by the
Then, from early January to late February, he had five falls in 52 days, resulting in bleeding and abrasions to his head.
Department documents say Nelson's nurse had suggested a number of possibilities to lessen the impact of a fall: "bed/wheelchair alarm, pendant alarm, assessment of possible causes of frequent falls, providing supervised and assisted ambulation, 24-hour personal caregiver" or a "protective mattress on the floor."
The department found
'A fall issue'
Nelson had a bad fall in early May and was found unresponsive on the floor of his room. He was treated at UC Davis for a head injury. After, he had a brief stay at Sherwood Healthcare Center, a skilled nursing facility in
"He was very unsteady on his feet," Alexander explained. "And they were concerned about him falling."
When he returned to
According to department documents, the executive director of the facility said alarms were not allowed "because the facility could not guarantee that the alarms would be heard by staff members."
During Nelson's time in the facility, from June to August, there was, as
Alexander said he knew about only one or two falls his stepfather had while in this facility, but department documents show there were far more.
The documents show
Nine falls in 21 days
The staff at
He moved into the new facility in late July.
In late August, Alexander spoke with his stepfather's neurologist and said the family had been waiting three or four weeks for
"She said, 'You shouldn't have to wait,' "
Alexander-Nelson said she and her family were nagging staff to install the alarms -- "it was maddening."
In late July,
"This, despite the fact that one of the main reasons Alan was moving into the Memory Care Unit was due to the urgency to respond to a high fall risk," Alexander added.
The following Sunday, Alexander was checking in on his stepfather when he ran into Schumann, who promised him a staffer was placing the alarms immediately.
Hours later,
A CT scan showed a "blood clot in the left frontal lobe, small amount of air or gas in the left frontal region and fractures on the left frontal bone and left cheek bone."
He was sent to the ICU at Mercy San Juan. His stepson and wife made arrangements to move him from
Department documents show he had nine falls in 21 days in the month of
According to state documents, his cause of death is listed as "acute respiratory failure, septic shock, bilateral pneumonia with other contributing conditions as subdural hematoma." The subdural hematoma was blood that collected between the surface and covering of the brain after he fell and hit his head.
The aftermath
"I feel terrible guilt and remorse that I didn't catch onto this more quickly," she said. "It's like I never understood. I think I was sort of intimidated by this whole medical (system). I wanted to believe it was a good place. I question my own ability to have protected him and I can imagine a lot of people feel the same way."
After her husband's death, Alexander-Nelson and her son decided to file a complaint, but "had no idea how it would be done," Alexander said. They came across an article published in
FATE is a
filed a complaint about the circumstances surrounding Nelson's time at
According to those findings,
Herman said she was frustrated the department took over a year to release its findings. "I'm a believer in justice delayed is justice denied," she said.
Herman, however, feels there may have been serious ramifications to what she feels was a delay by the state.
While she was waiting for the state's findings, she filed a separate complaint about an 85-year-old patient who fell on 20 separate occasions, resulting in "an open lesion in back of his head." He was also a patient at
"If you had expedited this complaint, perhaps this other client would not have been injured," she said. "It could've prevented this other man from dying."
A complaint investigation report posted on the department's website in July details the case of a patient who suffered multiple falls resulting in injury.
"Facility staff neglected resident resulting in stage 3 pressure injury," the report concludes. "Facility has insufficient staffing to meet resident needs."
On
"It's not nearly enough for what happened to that man," Herman said.
According to Weston, the state developed a plan of correction, including an in-service, two-hour training to be conducted by an outside agency to address "proper observation and monitoring of residents and a statement verifying procedures were in place to adequately re-assess residents with significant changes in condition. "
A signed training log was required to be submitted to the department of Social Services' community care licensing division by
It's difficult for
"What did I learn? I ask myself that,"
___
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