California Convalescent Home Fined Maximum $100K in 2006 Death

The California Department of Public Health has fined Bakersfield Health Care, a skilled nursing facility in Bakersfield, $100,000 -- the highest fine allowed by state law -- and issued the most severe "AA" citation to the facility because of staff errors that led to the Oct. 20, 2006, death of a resident, CDPH Director Dr. Mark Horton announced Thursday. The errors were failing to address gastrointestinal bleeding caused by the interaction of two medications: Coumadin (Warfarin), a blood thinner, and Mobic, a non-steroidal anti-inflammatory drug (NSAID).

The department's investigative report (www.cdph.ca.gov/certlic/facilities/Documents/sodBakersfieldHealthcare_ZKSJ11.pdf) indicates the patient refused laboratory blood draws for a test that would have monitored the effects of the Coumadin, but the nursing staff apparently failed to address the refusals or the use of Mobic, which was a major risk factor in the patient's care because of the known risk of developing bleeding gastric ulcers from concurrently using oral anticoagulants and NSAIDs. The resident was initially admitted to Bakersfield Health Care on Sept. 7, 2006, with diagnoses that included atrial fibrillation and back pain, according to the report. After being transferred to an emergency department on Oct. 20, 2006, the resident required resuscitation and was declared dead 15 minutes into the resuscitation (12 hours after the transfer); the ED physician documented that the patient "has essentially bled out through . . . GI tract and attempts at further resuscitation are futile," the report states.

There are about 1,400 skilled nursing facilities in California, which can fine nursing facilities it licenses for poor care and issue citations that are categorized as Class B, A, or AA. The associated fines range from $100 to $1,000 for Class B, $2,000 to $20,000 for Class A, and $25,000 to $100,000 for Class AA.

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