Just because a doctor orders something for a resident in a nursing home, it does not mean it gets done – sometimes with lethal consequences.  A California state investigator found that Pilgrim Haven Health Facility in Los Altos failed to install an electronic fall monitor as ordered by the resident’s doctor, and failed to make sure the resident’s walker was in reach.   As a result, the man fell twice, and died from head trauma.  The nursing home was fined $100,000 by the state.

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