Ninety-two-year-old Robert Doscher was admitted to Valley Gardens Health Care, a for-profit nursing home, on May 18, 2007. He came from a hospital where he was being treated for a mini-stroke, and other heart issues. Upon admission to the nursing home, he needed the use of a walker, and the plan was to stabilize his health, and transfer him to an assisted living facility.
He required the use of a walker when he was admitted, and it was initially planned that he could be discharged to a board-and-care facility when his condition stabilized. The admission assessment at Valley Gardens determined that Doscher was at “high risk” for falling, and the care plan ordered the he be checked “every one to two hours.” He was also instructed not to get up without assistance, and a tab alarm was placed on his clothing to monitor his movements.
On May 21st, only three days after he was admitted to the nursing home, Doscher fell and struck his head on the floor. He was found by staff on the floor. According to the investigation, there was no evidence that Valley Gardens was checking on Doscher every one to two hours, nor did they place him near the nursing station, as had also been recommended upon admission.
Approximately three weeks later, on June 12, Dosher was again found on the floor, and, according to the medical records, Doscher “rapidly developed a change in condition manifested by agitation and then a decrease in his level of consciousness.” The following day he was taken to the hospital in a comatose state, and died within 24 hours.
The California Department of Public Health was called to investigate Doscher’s death, and issued a “AA” citation and a $90,000 fine for inadequate care that it found led to Doscher’s death.
Valley Gardens is owned by Kindred Healthcare Inc. of Louisville, Ky. Kindred had revenue of more than $4 billion as of June 30, 2009 and operates 222 skilled-nursing facilities nationwide.
Source: Recordnet.com
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