Westlake nursing home fined $100,000 for patient death
The case involved an 83-year-old man, who on the morning of Jan. 4, 2007, lost his balance and struck his head on a bed rail when he was being moved from his bed to a wheelchair. The man had a short-term memory problem and had impaired cognitive skills, and relied on nursing staff for dressing; state officials said the facility failed to provide adequate support for the resident as he was transferred to his wheelchair.
At 8:30 a.m., about half an hour after the blow to the head, nurses' notes documented the man had a bluish discoloration on the left side of his head. Staff monitored the patient’s condition as the attending physician was paged at 8:45 a.m. and 12:30 p.m., but the doctor did not return the call.
His condition continued to deteriorate throughout the day; he refused lunch and dinner and complained of not feeling well. At 8:30 p.m., he was observed as lethargic. Finally, at an unspecified time, an attending physician was reached, and the patient was transferred to a hospital at 9:30 p.m.—more than 13 hours after he had struck his head. The patient had suffered bleeding in the brain and died five days later.
Investigators said the licensed nurses should have called either an alternate physician or the medical director when the attending physician did not respond to pages, or call 911 in an emergency.
“Failure of the facility staff to immediately notify the physician and to provide the necessary care and services to Resident 1 [the patient] ... presented a substantial probability that serious harm would result, and did result to Resident 1 [the patient’s] death,” the report said.
Nursing home administrator Kim Elliott said the facility has not decided whether to appeal the fine.
“Our hearts go out to the family, and obviously, any loss of life is a tragedy,” Elliott said.