By Khalida Sarwari
A San Jose convalescent hospital is being fined $80,000 for patient care that the state public health department claims led to the death of an 83-year-old woman earlier this year.
San Tomas Convalescent Hospital was given the most severe penalty under state law following an investigation by the California Department of Public Health.
A nine-page report released by the health department claims an alleged lack of adequate care and supervision resulted in the death of an Alzheimer’s patient with unsteady gait.
On April 3, the patient was walking unsupervised in her room and pulled a television off a dresser, causing both to come down and crush her. The patient suffered fractures of her facial bones and the orbit of her left eye, and bleeding within the brain. She died nearly two weeks later.
The Santa Clara County medical examiner’s office identified Hannah Lesser, of San Jose, as an 83-year-old woman who died on April 16 of blunt trauma of the head with skull fractures.
According to the report, the hospital failed to ensure a safe and hazard-free environment for Lesser, who was admitted to the facility on March 3 with a history of frequent falls, restless leg syndrome and major depression.
Furthermore, the report claims that the hospital had not updated and implemented a care plan regarding fall prevention.
Lesser’s care plan included around-the-clock supervision and the use of a personal alarm, but a personal alarm was not available at the time of her fall, according to the report.
The report states that a physical therapy recommendation on March 25 to receive assistance at all times when walking was not included in her care plan.
A nurse who was assigned to care for Lesser that night told investigators that he had put her to bed at about 8 p.m. and then had gone to an adjoining room to care for another patient, leaving a wheelchair and a walker near her bed.
The nurse said just three minutes later he heard a loud crash in the room and returned to find Lesser lying on her back with a dresser lying across her lower body and a flat-screen television on top of her head and chest.
The television was attached to the dresser with straps, the nurse said, and it appeared as though Lesser had tried to remove the television from atop the dresser.
According to the Department of Public Health, the citation process is an attempt to protect the health and safety of residents and is part of an ongoing effort to improve the quality of care provided in intermediate care facilities.