The California Department of Public Health issued a $90,000 fine to a nursing facility, Del Rosa Villa, after the facility failed to prevent a patient’s suicide.   Public Health’s investigative report shows that the patient was admitted to Del Rosa Villa on May 22 about one month after he broke two bones in his left leg by throwing himself in front of a car.  The man had been diagnosed with depressive disorder, schizophrenia and "suicidal ideation."   A care plan dated June 1 set forth that he was to be on "suicide watch at all times," according to Public Health’s report.  On June 11 the man was found hanging from a fence in the parking lot.

A nurse told Public Health that around 12:30 a.m. June 11, she saw the man leaving the nursing home’s laundry room alone in a wheelchair to smoke.  About 20 minutes later, the man was found outside hanging from a fence with a belt around his neck. He could not be revived after being cut down and given CPR.

Public Health concluded that Del Rosa Villa personnel failed to abide by the care plan’s call to place the man under suicide watch and was a "direct proximate cause of the death of the patient."   The report says the man was supposed to be under a constant suicide watch, but that was not done.

The report said "suicide watch at all times" was written on the man’s care plan, and that a licensed vocational nurse working at the facility told investigators, "I missed it. I didn’t see it."

The state issued a AA citation to the facility, which is the most severe penalty under law.

 

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