Maximum Fine Issued in Rehab Center Patient's Death

The maximum penalty allowed by California state law has been assessed against Aviara Healthcare Center, a skilled nursing and rehab center in Encinitas, Calif., after a patient died May 13.

The California Department of Public Health announced June 22 it has issued the maximum penalty allowed by state law, a $100,000 fine and "AA" citation, to Aviara Healthcare Center, a skilled nursing and rehab center in Encinitas. The department's investigation determined that failure to store a Hoyer mechanical lift properly resulted in a male patient's death May 13, announced Dr. Mark Horton, the department's director.

CDPH said Aviara created a hazard by improperly storing the lift in a hallway. The patient grabbed the lift during a May 10 fall, tipping it over, and he struck his head on lift's metal frame as he fell. This caused severe bleeding in the patient's brain. His death was attributed by the coroner to blunt force trauma to the head, exacerbated by renal disease, according to the investigative report.

The lift moved as the patient fell because its wheels had not been locked, a registered nurse who witnessed the fall told CDPH investigators. Staffers also said the lift was supposed to stored in a shower room when not in use, but it was placed in a corridor 1 foot outside the patient's room at the time of the fall and was still there on May 13 and May 17, according to the report, which says there was no hand rail to assist patients in that part of the corridor.

All 1,400 nursing facilities in California are required to comply with applicable state and federal laws and regulations governing health care facilities; CDPH has enforcement authority aimed at improving the quality of care provided to residents of those facilities.

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