California Department of Health Services Cites Nursing Home in Death of a Patient

SACRAMENTO Emerald Gardens Nursing Home in Sacramento County has received a "AA" citation from the state of California, the most severe under state law, State Public Health Officer Dr. Richard Joseph Jackson announced.


The facility received the citation and an $80,000 fine after an investigation by the California Department of Health Services (CDHS) concluded that poor care of a 56-year-old female resident led to her death.


The resident was admitted to the facility on April 17 with sepsis, bedsores, anemia and respiratory failure. Records show the resident needed extensive assistance with getting in and out of bed and day-to-day activities. She had limited use of her arms and shoulders. Her physician ordered an air mattress to relieve bedsores.


On May 5, the resident was found unresponsive in her bed, trapped between the air mattress and the bedside rails. After being freed, she was pronounced dead at the facility after cardiopulmonary resuscitation failed to revive her. The autopsy report documented the cause of death to be "sudden cardiac arrest while wedged between the bedrail and mattress."


CDHS investigation found there was a "gap of approximately four inches between the air mattress and the side rails of the bed." It determined that the facility failed to properly assess the dangers of the air mattress and ensure the residents rights to be as free as possible from potential hazards.


The investigation included a review of medical records, interviews with facility staff and a representative of the mattress company and a review of the coroners report. Emerald Gardens has a number of options for appealing the citation. The fine is not payable until any appeals are adjudicated. However, the facility must immediately implement a plan to prevent recurrence.


Source: California Department of Health Services