Visalia care facility fined after 80-year-old given toxic medication, causing death
A skilled nursing care facility in Visalia was fined $120,000 after an 80-year-old woman was given a weekly chemotherapy medicine too often until it reached toxic levels, contributing to the patient’s death, according to the state Department of Public Health.
State health officials issued the fine to Sequoia Vista Care on May 27, according to public records. The facility is owned by Sweetwater Care, a San Diego-based company that has been sued by state Attorney General Rob Bonta’s Office.
An administrator who answered the phone at the Visalia facility on Thursday declined to comment or provide a corporate contact. Requests for comment to the Carlsbad and San Diego corporate offices from The Bee went unanswered.
Sequoia Vista specializes in short-term rehabilitation and long-term care, according to its website.
Following a complaint earlier this year, the health department conducted an investigation and found the facility and its staff did not follow the guidelines for the chemo drug methotrexate, which helps to slow the growth of cancerous cells but was prescribed to the patient at 20mg once a week.
The patient was given the drug by my mouth daily for about three weeks despite automated warnings until she was taken to a hospital on Dec. 18, the records say. The report also noted the woman had bleeding from her nose and gums as well as in her stool, which were signs of adverse effects.
She died Jan. 31, and the report said staffers had failed to ensure they were providing the woman, whom investigators called “Resident 1,” with the medication properly. “These failures resulted in Resident 1’s death,” the records say.
Fined for improperly administering medication
An investigator for the health department made an unannounced visit to the Visalia facility on Jan. 12, according to records.
The patient was described as an 80-year-old woman who was diagnosed with rheumatoid arthritis, shortness of breath and difficulty walking when she was admitted to Sequoia Vista on Nov. 19, the records say.
The staffers missed the automated “system-generated medication alert warning” that the patient was receiving too much of the medication, the health department report said. They also did not investigate adverse symptoms the woman was showing, including bleeding, the report noted.
Along with painful open sores, the woman suffered kidney failure from toxic levels of the medication, the report said.
The public health investigator interviewed the assistant director of nurses on March 12, the report says.
“I feel like this could have been caught and not sure why the system failed,” the director of nurses said, according to the report.
