Northern California nursing home is fined $100,000 over patient's death

The 85-year-old patient, who had a heart condition and diabetes, was supposed to use a walker and be supervised when walking, according to a state investigator's report released Aug. 3 on Pilgrim Haven Health Facility in Los Altos.

But a state investigator found Pilgrim Haven staff members failed to install an electronic fall monitor as ordered by the patient's doctor and also failed to ensure that the patient's walker was within reach. On Oct. 3, staff members discovered the man sitting on the floor of his room, having fallen and scratched his head, according to a fax sent to his doctor.

(...) On Dec. 7, staff members found the man collapsed on the floor of his room, away from his walker, where he told them he had fallen, according to staff notes reviewed by the state investigator.

The man denied that he had hit his head and he was given a neurological evaluation that appeared normal, according to staff members' notes. However, when he turned pale and listless and started vomiting later that night, staff members did not assess him for possible head injuries or notify his doctor for about two hours, in part because there was no registered nurse on duty that night, according to the patient's medical records.

After staff members notified the patient's nephew and doctor, they had the man transferred to a hospital, where he died the next morning. Doctors used a CT scan to determine that the cause of death was bleeding in the brain and a fall with head trauma, according to medical records cited in the investigator's report.