Resident’s death triggered inquiry
Jim Steinberg, Staff Writer
Posted: 06/29/2011 08:57:57 PM PDT

SAN BERNARDINO – The state’s Public Health Department on Wednesday announced an $80,000 fine and a “severe” citation slapped on Community Hospital of San Bernardino, after finding that a nursing facility resident died in 2008 because staffers failed to ensure proper assisted breathing.

The hospital received an “AA” Citation – the state’s most severe – and the fine after an investigation concluded that a man who was admitted July 27, 2007, with emphysema and asthmatic bronchitis died the following February.

On the morning of Feb. 2, 2008, “the patient’s ventilator gauges showed abnormal readings and the ventilator alarm was not audible,” according to the state’s report. And his ventilator tube – which he was dependent on to help him breathe – was found disconnected.

Ultimately, investigators found a series of missteps, according to investigation documents, including failure to ensure that only staff trained and proficient in caring for ventilator-dependent patients care for them; a failure to maintain caregiver competency; they found that the facility didn’t ensure staff performed ventilator checks every four hours as required; and they concluded that staff failed to “continually assess” the man after medical staff noted a change in his respiration.

As a result, the man died, the report states. Neither the man’s name nor age was released, because of privacy restrictions.

Community Hospital – part of the San Francisco-based chain of medical facilities, Catholic Healthcare West – did not contest the state’s findings and has paid the fine, spokeswoman Tobey Robertson said.

But in a statement, hospital officials said they conducted their own investigation and are working with medical staff, patient care staff and hospital administrators, and the California Department of Public Health to “ensure that an incident like this never happens again.”

The “AA” citation is the most serious level of violation and requires a fine in the range of $25,000 to $100,000.

This was only the fourth “AA” fine issued statewide this year. Last year, a total of eight were issued, state health officials said, adding that the enforcement effort was part of ongoing efforts to improve care for residents of the state’s roughly 1,400 skilled-nursing facilities.

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