The California Department of Health Services issued the following press release:
Bruceville Terrace Skilled Nursing Facility in Sacramento County has received a 'AA' citation, the most severe under state law, and a $100,000 fine, the highest fine under state law, from the state of California after an investigation by the California Department of Health Services (CDHS) concluded that poor care of a 74 year old resident led to his death, State Public Health Officer Dr. Mark Horton announced today.
Records show that the resident had a terminal illness and was admitted for comfort care and symptom management. He required total assistance for all daily living activities.
On Oct. 17, 2006, a significant medication error occurred, and the resident received a massive overdose of intravenous morphine. He died almost immediately after the error occurred.
CDHS determined that the facility failed to administer the medication as ordered by the physician, monitor the resident's response to the medication, follow the facility policy and procedure for medication administration and documentation and promptly notify the physician of the medication error.
The investigation included observations of the facility, multiple interviews with staff and a review of medical records and facility documents. The facility has implemented a plan of correction to prevent future incidents.
All nursing facilities in California are required to be in substantial compliance with applicable state and federal laws and regulations governing health care facilities. Facilities are required to comply with these standards to ensure at least a minimum level of quality of care.
California has the statutory authority to impose substantial fines against nursing homes as an extra tool in its arsenal of enforcement remedies for poor care. The 'AA' citation process is part of CDHS' ongoing enforcement efforts to improve the quality of care provided to residents of the state's approximately 1,400 skilled nursing facilities. By providing nursing homes with consequences for substantiated violations, CDHS strives to protect the health and safety of its most vulnerable individuals.Contact: Mike Bowman , Norma Arceo, 916/440-7660.
Mike Bowman , Norma Arceo, 916/440-7660.
