A Santa Monica nursing home has been fined $100,000 and issued a class AA citation by the California Department of Public Health (DPH) for allegedly causing the death of an 88-year-old resident last year.

The citation alleges that Arbor View Rehabilitation and Wellness Center’s violation was a “direct proximate cause” of the resident’s death. The $100,000 fine issued in this case is the most severe allowed by California law.

According to the DPH citation, on August 29th, 2008, a hospital inserted a gastrostomy tube into the resident’s stomach to allow her to directly receive nutrition, fluids and medications. The resident was readmitted to Arbor View five days later. Her feeding tube became dislodged at Arbor View on September 8th, and a licensed vocational nurse reinserted it and continued the resident’s tube feedings, according to the citation.

The resident was hospitalized the next day due to vomiting, nausea and other symptoms. A hospital scan found that the feeding tube had been inserted into her abdominal cavity instead of her stomach and showed massive amounts of fluid in her abdomen, the citation states.

The resident did not recover and died on October 24th. An autopsy report indicated that she died due to complications of inflammation of the lining of her abdominal cavity.

Arbor View’s policy on gastrostomy tubes permits licensed nurses to change or reinsert these tubes only when they are in place for three months or more, according to DPH. The resident’s tube had only been in place for approximately ten days, and hospital orders stated that the radiology department should reinsert or replace the tube if it fell out to ensure proper placement, the health department said.

The Santa Monica facility was fined earlier this year for neglecting other residents who died, a department spokesperson said.

Ruth Jackson, Arbor View’s new administrator, was not available to comment on the citation and fine as of Argonaut press time.

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