SACRAMENTO - Coastal Communities Hospital Distinct Part Skilled Nursing Facility of Orange 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. 13.

The facility received the citation and a $75,000 fine after an investigation by the California Department of Health Services (CDHS) concluded that poor care of a  45-year-old resident led to his death.

The resident was admitted to the facility on March 15, . Records show the resident required complete care for day-to-day activities and was ventilator dependent.

On July 30, , the respiratory therapist attempted to change the resident's tracheotomy tube without the assistance of a licensed nurse or another respiratory therapist. The respiratory therapist was unsuccessful and left the resident unattended to obtain assistance. The doctor on call in the hospital’s emergency room was called and resuscitative efforts were attempted, but unsuccessful. The resident was pronounced dead by the emergency room doctor. The coroner's report listed the cause of death as respiratory failure and difficult reinsertion of the tracheotomy tube.

CDHS' investigation determined that the facility failed to develop a care plan addressing difficult tracheotomy tube changes and failed to follow policies and procedure for tracheotomy tube changes, resulting in the resident's death.

The investigation included a review of medical records and interviews with family members, facility and medical staff. Coastal Communities Hospital Distinct Part Skilled Nursing Facility has a number of options for appealing the citation and is not required to pay the fine until any appeal is completed.

Source: California Department of Health Services