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Veterans Home Fined in 3rd Patient's Death

Health: This time, Barstow facility is penalized $10,000. Unlike the two previous cases, the quality of care was not linked directly to the fatality.


SACRAMENTO — For the third time in three months, patient care violations have been discovered in connection with the death of a resident at the troubled California Veterans Home at Barstow, state health officials disclosed Monday.

The Department of Health Services fined the state-operated veterans nursing facility $10,000 in the May 30 death of a diabetic former sailor.

It is the third case since May in which a fine has been issued in connection with the death of a resident of the home for elderly and disabled military veterans.

The fine was the maximum allowed for cases in which the quality of patient care is an issue but cannot be identified as the direct cause of death, a state health services official said.

The health department in June fined the home an unprecedented $64,500 for various violations after the deaths of two patients. The department also warned the home that its license was again in jeopardy.

One man allegedly choked on a piece of broccoli at lunch. The second died in a diabetic coma.

In the latest case, officials said William J. King Sr., 62, who served in the Navy in 1974 and 1975, was admitted March 1, 1999, and suffered from a variety of illnesses, including diabetes and depression.

In their report of King's death, health department investigators cited numerous patient care violations, including the failure of nurses to report King's refusal to accept all of his meals for weeks at a time.

Additionally, the investigators said, King only sporadically submitted to weekly blood glucose monitoring from December through May. Proper diet and monitoring blood sugar levels are key elements in the treatment of diabetes.

Moreover, the investigators said, orders by King's physician that he was to be notified of abnormal blood glucose and kept advised of his behavior were violated.

On May 25, five days before King's death, a nurse noted that King had "been asleep in his bed all day. He has refused to wake up or eat or take his medications. Resident was unresponsive to verbal or physical stimulation by nurse."

But there was no documentation, the investigators said, to indicate that the nursing staff then took steps to "assure that the patient was not suffering from diabetic symptoms."

On May 30, King was found "unresponsive" on his bed. A nurse and 911 paramedics were called. A death certificate said King died of heart failure, according to John Hagerty, a health department licensing official. There was no autopsy.

The latest fine brought to $694,500 the total of state and federal sanctions levied against the veterans home since May.

The action represents another setback for Gov. Gray Davis' campaign to turn around the quality of care at Barstow, a state-of-the-art facility when it opened four years ago.

For more than a year, the home has been struggling to keep its nursing home license and its substantial state and federal funding.

Jerry Jones of the Department of Veterans Affairs, which operates the home for about 270 patients, said a notice of intention to appeal the fine would be filed. But he said it was uncertain whether an appeal would be pursued.

The federal Department of Veterans Affairs in May cut off $300,000 in monthly payments because of the home's failure to comply with patient care and management standards. The federal Health Care Financing Administration took a similar action early in July, refusing to make payments of $320,000.

In the deaths of the two veterans earlier this year, the health department issued a "Class AA" citation, in which patient care was directly linked to the cause of death.

In the case of King, however, the department issued a Class A citation, its second-most severe fine.

"We do not have any direct link to say these things that we pointed out [in King's report] were the exact cause of death," Hagerty said. "We do not have the information, such as might be provided by a coroner's report."

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