Disability Rights California Releases Findings of Nursing Homes Investigation

 the word oversight spelled out on white cubes

by Andy Jones
January 24, 2017

Chester Maples, a then 34-year-old man with developmental disabilities, resided at the Verdant Vista Nursing Facility. In 2009, he committed suicide by inhaling the contents of a fire extinguisher. Earlier that same month he had made two other attempts to end his life using the same method.

The California Department of Public Health, Licensing and Certification issued a Class AA citation, and the Attorney General's office filed a criminal complaint against the facility.

The next year, Alejandro Reynolds, a 30-year old man who used a wheelchair, developed numerous pressure sores on his back and legs, the largest of which measured 6 X 4 inches. Despite using two blood thinners, Verdant Vista allegedly lacked a care plan for his medications. On July 10, 2010, he bled uncontrollably and died a little more than an hour later.

This time, however, Licensing and Certification declined to issue a Class AA citation, issuing instead a Class A citation, allowing the facility to avoid suspension or possible license revocation.

Four years later, another resident at Verdant Vista died under circumstances allegedly so grossly negligent that the state Attorney General filed voluntary manslaughter charges.

Such inconsistent accountability practices are the focus of a new Disability Rights California report, released January 9.

“These cases were not isolated events,” DRC attorney Pamila Lew said in a news release. “We analyzed hundreds of cases and found that negligent care directly contributed to resident deaths. But the state issued lower level citations, which resulted in lighter penalties, sometimes seeming to significantly undervalue staff responsibility in the loss of life.”

For the investigation, DRC reviewed all citations issued by the agency issued against the states nursing homes between 2000 and 2014. During this time, it issued 259 Class AA citations, which are mandated where the facility was a “proximate cause” of the resident’s death. In 287 other instances involving a resident’s death, however, the Department issued a Class A citation, which are mandated where the facility poses an imminent danger to a resident or a substantial probability of death or serious injury.

“Licensing appears to lack consistent standards for determining whether to issue a Class AA citation in the case of a patient death…,” the report states. “In many cases, the deaths involved a seemingly identical fact pattern.”

Among the report’s recommendations, DRC is demanding more consistent standards, transparency in how the agency comes to its conclusions and harsher standards for violators.    

The full report, titled Keep Nursing Home Residents Safe, can be read here [PDF].

Disability Rights Washington and Disability Rights California are the designated protection and advocacy agencies in Washington and California, respectively, and are members of the National Disability Rights Network.