California nursing home fined for dropping wheelchair user from mechanical lift, which led to her death

From the Los Angeles Times:

A Northern California nursing home was fined $100,000, the highest penalty under state law, after a mechanical lift that was not properly maintained broke and dropped a patient who injured her head and later died.

The 60-year-old patient, who had a heart condition, diabetes and a muscle wasting disease, was confined to a wheelchair and needed help getting up and into bed, according to a California Department of Public Health investigator’s report released Tuesday on Eskaton Care Center Manzanita in Carmichael.

A state investigator found Eskaton Care Center Manzanita staff failed to maintain the lift used to transfer the woman to bed. On July 20, 2008, as nurse assistants were transferring the woman from her wheelchair into bed, the lift sling holding the woman broke and she fell and hit her head on a nearby door, according to a nurse’s notes. The woman was transferred to an emergency room, where medical records show she later suffered bleeding in her brain, brain damage and a stroke. She died four days later.

The sling that broke was supposed to be checked monthly, but had not been checked in five years, according to the facility maintenance director.

Eskaton Care Center Manzanita is one of 35 properties and programs operated by Eskaton, which is based in Carmichael and serves about 14,000 people annually, including about 3,000 residents, according to spokesman Stuart Greenbaum.

In a plan of correction submitted to the state, nursing home officials said they had required more frequent inspections of the lifts and trained staff to better inspect and operate them.

Eskaton officials did not dispute the investigator’s findings, but were still considering Tuesday whether to appeal the fine, according to Trevor Hammond, the company’s chief operating officer.

“We feel very sad that it did occur,” Hammond said.