87-year-old patient falls while being moved and home gets severe citation
More bad publicity for the Motion Picture and Television Fund’s (MPTF) long-term care facility.
The MPTF, currently feeling the sting from its controversial decision to shut down its hospital, has been slapped with a $7,500 fine from the California Department of Health for failing to prevent an injury to an 87-year-old resident.
The resident in question hurt her head nearly a year ago after she fell to the floor while being transferred from her wheelchair to her bed. The citation notes that only one nurse was moving the resident, even though hospital protocol calls for two nurses to be involved in such a transfer. The patient had a Y-shaped laceration on her head with cranial bone exposed after slipping out of the sling being used to move her to the bed.
Members of Saving the Lives of Our Own, the grassroots group formed to keep the hospital open, said the incident reflected a decline in the level of care at the facility since the MPTF board announced plans to close it in January 2009.
"It indicates that there has been a diminution in services, and that has had a negative effect on the residents and their care," Andrew Suser, co-founder of the group, told TheWrap. "I think that there’s an overall problem in which the decision by the MPTF leadership to single out the most sick and needy residents creates a breakdown of morale because it shows a lack of moral leadership at the top."
Suser’s co-founder, Nancy Biederman, laid the blame squarely at the feet of now-departed MPTF CEO David Tillman, who resigned abruptly last February.
"Clearly there is an association between a hospital’s organizational culture and potential resident safety events," Biederman said. "MPTF’s former CEO David Tillman recommended, and the COO implemented, changes influenced by their consultant, the Camden Group.The changes resulted in a reduction in commitment to the patients at the long-term care facility as well as the organizational commitment to the values and historical mission of the MPTF."
The MPTF, however, sought to portray the fine as an anomaly and noted that the employee in question had been counseled.
"This is an isolated incident. There is no connection between this incident and our announcement about the closure of long-term care," Steve Honig, a spokesman for the MPTF, told TheWrap. "It occurred because one employee did not follow proper procedure.
Honig noted that the patient has fully recovered from her injuries and is one of the roughly 54 residents still living on campus.
Yet Saving the Lives of Our Own suggested that the failure to have two nurses involved in moving the resident was the result of staff cuts enacted at the facility. Honig disputed those charges.
"This incident had nothing to do with staffing," Honig said. "It involved one employee and staffing was not the cause."
Mike Connors, a spokesman for California Advocates for Nursing Home Reform (CANHR), disputes Honig’s claims that this was a unique event. He says the report states that multiple employees expressed ignorance that two staff members were required to operate the mechanical lift used during the patient’s fall. Connors also notes the citation said the employee in question had continued to transfer patients with the lift and without any assistance even after the May 28 accident.
"It was a serious injury to the resident that should have been avoided and could have been avoided if the MPTF had enough staff and had trained its staff properly about these dangerous solo transfers," Connors told TheWrap.
Department of Public Health citations have three letter grades — B, A and AA — with AA being the most severe. The citation issued against the MPTF was graded class A, and is one of roughly 100 given out annually, according to a department spokesperson. The last time the long-term care facility was cited was for a grade B violation involving medication that took place in 2004.
The fine comes on the heels of news that the MPTF is consolidating all of its long-term care residents into a single facility. The remaining 25 people currently residing in the Pavilion will join the other residents in the newer Skilled Nursing Facility. That move is supposed to be completed by June 18.