SACRAMENTO – CareMeridian Congregate Living Health Facility in Ventura County has received a "AA" citation from the state of California, the most severe under state law, State Public Health Officer Dr. Richard J. Jackson announced Jan. 12.

The facility received the citation and a $25,000 fine after an investigation by the California Department of Health Services (CDHS) concluded that poor care of a 20-year-old male resident led to his death.

The resident was admitted to the facility on Jan. 20, . Records show the resident was comatose and received his nutrition, hydration and medication through a gastrostomy tube, also known as a G-tube, that extends through the abdominal wall into the stomach.

On June 2, , the resident's G-tube was dislodged and reinserted into his abdominal cavity instead of his stomach. Facility staff continued to provide feeding solution, water and medications to the resident through the tube until they noticed he was in distress and had abnormal vital signs. Paramedics called by staff found no pulse or respiration, and the resident was pronounced dead at the facility. The autopsy report listed the cause of death as peritonitis caused by infusion of feeding solution into the abdominal cavity due to misplacement of the G-tube.

CDHS determined that the facility failed to ensure that the G-tube was properly reinserted and failed to verify its proper placement prior to providing feeding solution, water and medications through the tube.

The investigation included interviews with facility staff and the resident's physician and a review of the medical records, autopsy report and death certificate. CareMeridian has a number of options for appealing the citation and is not required to pay the fine until any appeal is completed.

Source: California State Department of Health