State fines skilled nursing facility for death of resident


Redwood Springs in Visalia is hit with state’s most severe penalty after unsupervised patient fell, hit her head and died six days later

By Reggie Ellis @Reggie_SGN

VISALIA – A skilled nursing facility in Visalia received the most severe penalty under state law after a patient fell off the toilet and hit her head which ultimately led to her death. 

On July 12, the California Department of Public Health (CDPH) announced that Redwood Springs Healthcare Center had received a Class “AA” citation and a $100,000 fine from the State of California for leaving the woman, whose name is being withheld for privacy, unattended even though her medical records required her to be under supervision. 

According to CDPH, which oversees enforcement efforts in improving the quality of care at the 1,200 skilled nursing facilities in the state, the incident happened on Aug. 29, 2017 when two certified nursing assistants (CNAs) assisted the 81-year-old woman in using the commode, a plastic chair on wheels which goes over the toilet.

During a site visit on Sept. 12, 2017, CDPH interviewed two CNAs who stated it took both of them to lift the patient onto the toilet but once she was on the commode one of the CNAs left. The remaining CNA went into the next room to grab clothing for the patient when she heard a loud noise and realized the woman had fallen and was bleeding from a three-inch gash above her left eye.

The patient was taken to the emergency room where she received a CT scan and stitches to her left forehead. She was reportedly “doing great” just two days later until family members noted that she was not acting normally. On Aug. 31, 2017, the woman was admitted to the hospital around noon “for acute left subdural bleed [a life-threatening injury that occurs when blood vessels rupture between the brain and its membranes and the blood presses on the brain tissue].”

At 12:58 p.m. that day, the physician at the hospital wrote, “There was an acute impairment of an organ system with high probability of imminent or life threatening deterioration in the patient’s condition.” The woman died on Sept. 4, 2017.

Seth Braithwaite, administrator at Redwood Springs, said he could not comment on current litigation or the report due to patient privacy but did release the following statement: “There’s nothing more important to me than the health and safety of our residents as well as our employees. Everyday, everyone on our team is working hard to provide the highest of quality care and making sure we are compliant with all regulations.”

CDPH’s report concluded, “The facility failed to supervise Patient 1 while she was using the toilet. This a failure resulted in her falling and hitting her head on the floor, causing bleeding inside her skull. Patient 1 died six days later. This failure presented imminent danger that death or serious harm would result or substantial probability that death or serious physical harm would result therefrom, and was a direct proximate cause of Patient 1’s death.”

The patient’s minimum data set (MDS), a comprehensive assessment tool, stated that the woman was “Not steady, only able to stabilize with staff assistance” regarding “Moving on and off toilet” and that she required two people to assist her on the toilet. CDPH also noted that there was a warning on the bottom of the chair that reads, “Patient must never be left unattended or unsupervised.”

The woman was admitted to the facility on March 1, 2017 with diagnoses including diseases of the heart, muscle weakness, difficulty in walking, difficulty in swallowing, and left-sided weakness due to a previous stroke. 

On Dec. 27, 2017 the director of nursing (DON) reviewed the facility falls for the month of December and found that no other residents were found to be affected by this deficient practice. 

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