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Resident's Death Focus of Probe at Vets Home

Care: State is focusing on whether man's death at the facility in Barstow was reported accurately.


SACRAMENTO — A new investigation of the troubled California Veterans Home at Barstow is focusing on whether the choking death of an elderly former soldier was accurately reported, a top state health official said Tuesday.

It also was learned that state Veterans Affairs Secretary Tomas Alvarado had been at the 180-bed state-run nursing home for aging and disabled veterans, leading efforts to save its accreditation on Feb. 11, the same day 76-year-old Paul Stevens gagged on his lunch and died.

Veterans affairs officials say Stevens died of a heart attack. However, the San Bernardino County coroner's office concluded that he choked to death on his food--something that could be considered a sign of inadequate care.

The Department of Health Services, which at the time of the death was deciding whether to grant the home accreditation, has opened a new investigation into the cause of death.

Aides to Alvarado said they did not know whether Alvarado was aware of Stevens' death at the time. "He's unavailable," a department spokesman said.

Meantime, residents and staff members of the sprawling facility complained that several Department of Health Services investigators who took part in a surprise inspection Monday afternoon were carrying holstered guns.

"It was almost like a SWAT team hitting the building," said Dr. Mitchell Gold, the home's chief medical officer. "They announced they were peace officers, had arrest power and would take us out in handcuffs, if need be."

"This is a place of peace and tranquillity," said Ray Baker, 80, a wheelchair-bound former World War II fighter pilot. "I had no idea that inspectors were coming here armed."

Receptionist Vicki Kinder said patients and residents were "scared and fearful" at the sight of plainclothes health department investigators sweeping into the facility, displaying badges and carrying guns under their coats. "They've never come in armed before," she said.

Gov. Gray Davis authorized the investigation, which involved about 15 agents of the health department and the inspector general of the Veterans Affairs Department. It follows a series of new complaints, said state Director of Health Services Diana M. Bonta.

The Barstow nursing home, which is licensed by the health department and operates with both federal Medicare and state Medi-Cal funds, narrowly survived losing its accreditation earlier this year. If it had failed, federal funds would have been cut off.

Among other things, the home was criticized for sloppy management of records, a major violation. After a seven-month campaign to improve its performance, the veterans home was declared by the state health department to be in compliance with federal and state regulations, an action that protected its accreditation and funding.

But on Monday, the state agents returned unannounced in what Bonta described Tuesday as another full-scale investigation aimed at getting at "systemic" problems.

Bonta said that since February, at least four complaints had been filed against the Barstow home, including one involving the death of Stevens, a member of the U.S. Army in World War II.

Stevens, whose legs had been amputated, had been a resident at Barstow since March 1997. He suffered from a variety of ailments, including heart disease, high blood pressure, diabetes and colon cancer, said Glen Miller, a deputy coroner in San Bernardino.

Miller said Stevens had no history of swallowing or eating disorders. The coroner's report listed Stevens' death as "choking on food"--broccoli that had blocked his air passage.

But Department of Veterans Affairs officials contended that Stevens died of a heart attack while eating lunch in his room.

Miller said Stevens' food had been cut into small pieces to make it easier to swallow. "He was checked twice during the meal and eventually was found slumped over," Miller said.

Employees of the home applied emergency first aid and dislodged the broccoli. He was taken by paramedics to the emergency room at Barstow Community Hospital, where he was pronounced dead, Miller said. Stevens was "without air too long," Miller said.

Veterans Affairs officials dispute this and insist Stevens was alive when he left the Barstow facility.

"Our review shows he had been eating in his room and suffered a heart attack and expelled some of what he had been eating," said department Undersecretary Gerald Rucker.

He said heart attacks are a fairly common cause of death among aging veterans. Rucker said natural deaths are not considered reportable to the Department of Health Services.

Mike Madalo, acting deputy secretary for veterans homes, said the coroner's department based its finding of cause of death on notes compiled by a physician at the home.

"There was no autopsy, and the deputy coroner is not an M.D. He looked at the expulsion from [Stevens'] mouth," Madalo said.

But Bonta, who ordered the new investigation of Barstow, said inspectors are focusing on whether there was a "discrepancy" in how the home listed the death.

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