Inadequate Care & Negligence Lead to Man’s Death as Pilgrim Haven

Fatal Fall for Man, 85, Results in $100,000 Fine for Alleged Negligence by Northern California Nursing Home

September 22, 2010 — On December 8, 2009, an elderly man died—a death which could have been prevented with the proper medical care and attention. The man, 85, was a resident of the Pilgrim Haven Health Facility in Los Altos, a facility housing 50–60 people. Fined $100,000 for alleged negligence in the man’s death, Pilgrim Haven’s executive director, Rae Holt, has said that they intend to appeal the decision.

In a California Health and Human Services investigator’s report released on August 3, 2010, it was alleged that the staff at the skilled nursing facility had failed to adequately monitor the elderly patient. The fall resulting in the man’s death was the second one in a period of approximately two months.

His first fall occurred on October 3, 2009, when he was found sitting on the floor with a cut on his head. In a fax to the patient’s physician, an unidentified staff member wrote, “... sometimes he doesn’t use his walker which is dangerous for him.” His Minimum Data Set (MDS), an assessment tool dated October 8, 2009, stated that supervision was needed in walking as well as a one–man assist with bed mobility and transfers.

There was also an order from his doctor on December 2, 2008, to “check wanderguard daily for functioning.” A care plan for the man, revised on May 20, 2009, did not reflect the use of an electronic fall monitor like WanderGuard^®.

The fatal fall occurred on December 7, 2009. In the late morning, staff discovered him on the floor of his room by the foot of his bed after hearing him calling for help. His walker was in the middle of the room. He denied hitting his head and a neurological evaluation performed by Pilgrim Haven’s staff appeared normal. It was not until 7:00 pm that evening that he began displaying symptoms indicating a possible head injury. He appeared pale and listless, then vomited after eating a small amount of his dinner.

Two hours after the elderly man started displaying symptoms indicative of a neurological injury, the patient’s doctor was finally called. During the evening shift when his condition began to decline, there was no registered nurse to do consistent neurological evaluations to monitor him effectively. The staff on duty that evening consisted of a licensed vocational nurse and several certified nursing assistants. At 11:30 pm the man was transferred to the hospital where he died the next morning.

At a time when more and more people are facing the heart wrenching decision of placing an elderly loved one in a skilled nursing facility, this sad incident underscores the need for adequate staffing and stricter regulations in facilities like Pilgrim Haven. Elder abuse does not just encompass physical abuse but negligence as well.

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