O.C. Nursing Facility Gets State’s Severest Citation in Patient’s Death

A skilled nursing facility in Santa Ana has been fined $75,000 and reprimanded because the state said a respiratory therapist botched the replacement of a tracheotomy tube, killing a 45-year-old patient.

The unidentified man died July 30 at a 46-bed facility operated by Coastal Communities Hospital.

Results of the investigation by the state Department of Health Services, announced Thursday, determined that Coastal Communities did not have a plan for addressing difficult tracheotomy tube changes nor did it follow procedures for the changes, causing the man’s death.

The hospital is one of four being sold by Tenet Healthcare Corp. to a Costa Mesa firm whose chief financier operated several medical clinics that went bankrupt four years ago.

The state issued the hospital an AA citation, the department’s most severe sanction and one that is issued in the event of unjustified patient deaths. It was the only AA citation issued to the hospital since 1999, according to a California Advocates for Nursing Home Reform website that records citations as far back as that year.

The state issued 14 AA citations last year, a spokeswoman for the health department said.

Also on Thursday, an Ontario nursing home was fined $50,000 and issued an AA citation because of the death of an 88-year-old woman who allegedly was not given mouth-to-mouth resuscitation by care workers when they discovered she had stopped breathing.

A spokesman for the Inland Christian Home, where the woman died last January, said the facility planned to appeal the citation, arguing that the actions of the nursing home workers did not lead to the death.

All AA citations are sent to the state attorney general for potential prosecution. A spokesman for the attorney general’s office did not return calls.

The only other state sanction Coastal Communities has received since 1999 was a less severe class B citation given in 2002, for not watching closely enough the swelling of a 71-year-old woman’s foot. The fine for that level citation is $100 to $1,000.

Based on federal inspections, Coastal Communities has scored better than the state average, according to the nursing home reform website.

Patricia Bartel, the hospital’s vice president of business development, declined to comment, other than to say that Coastal Communities had submitted a corrective plan to the state Jan. 11.

It could not be determined if the therapist was fired.