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Inadequate Supervision

Published on August 13th, 2018

Redwood Springs Healthcare Center nursing home will pay $100,000 to the state’s department of public health after staff caused the death of a resident.  Redwood was given a Class “AA” citation — the most severe penalty under state law.  The patient suffered a preventable fall and injured her head. Doctors at the hospital told the family the fall caused the patient’s brain to swell. The injury resulted in her death.

An investigation into the complaint found there were “deficiencies” that directly led to the death of a patient at the facility.  During the investigation, they discovered that “the facility failed” to provide adequate supervision to an 81-year-old woman while she was using the toilet.

Following the patient’s fall, family said they called the facility to check on the woman. Staff told a family member the woman was “doing great.” However, when family went to visit the woman on Aug. 31 they said the woman wouldn’t wake up and was covered in sweat.

“The nurse said ‘she’s probably just tired from the fall,’” the complaint stated. “My sister called me and said we need to get her back to hospital.”

“They [the facility] shouldn’t have left her,” stated in the complaint. “They knew she couldn’t sit up on her own.”

Staff told CDPH investigators the woman fell when one of the two the Certified Nursing Assistant helping the woman turned around to pick up clothes.

According to the complaint, the patient needed two people when using the toilet.

Ultimately, investigators found that staff “failed to supervise [the woman] while she was using the toilet. This failure resulted in her falling and hitting her head on the floor, causing bleeding inside her skull.”

Joe Pioletti
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