A woman suffering from schizophrenia and other serious medical problems fell nine times in seven months before anyone at her nursing home acted to prevent further falls.

Her chart also describes six weeks last fall when she was behaving wildly — yelling, pacing, threatening staff and taking off her clothes, among other things. But none of her caregivers connected that to the fact that they failed during those same weeks to give her 22 doses of a drug to treat her mental illness.

For failing to provide that necessary care, Santa Rosa Care Center paid a $1,500 fine last week to the Arizona Department of Health Services, which licenses nursing homes and other elder-care facilities.

The woman is not identified in the health department's report, released to the Star last week.

Alan Beal, interim administrator at Santa Rosa, issued a written response to phone calls requesting an interview. Beal has overseen Santa Rosa since Jan. 23. The previous administrator was at the home less than three months, according to health department records.

"Santa Rosa Care Center, under its current ownership, scores annual quality ratings from ADHS of 'good' to 'excellent,'" Beal wrote. "That would equate to performance scores of 80 to 100 at the time of the survey."

In the health department's online listing of nursing homes, Santa Rosa has a current quality rating of "B," which means the center is 80 percent to 90 percent compliant with the department's minimum quality standards.

"If an error occurs or a mistake is made, we do a 'plan of correction' for ADHS and adjust our procedures to lessen the possibility that the same error would occur again," Beal continued.

Since Santa Rosa's current owners took control of the center in October 2002, "hundreds of thousands of dollars have been spent to improve the property and expand the operational knowledge of the staff," Beal wrote. "I have been in the industry for nearly 20 years, and know for fact that the staff at Santa Rosa is as fine and capable as the staff in any Arizona skilled nursing facility," the industry term for nursing home.

But Santa Rosa's violations illustrate the need for improvement at all levels of the elder-care system, said Stewart Grabel, ombudsman and director of elder rights and benefits at Pima Council on Aging.

"What was the plan for that patient with multiple problems and issues, and did the facility have adequate staff to carry out the plan?" Grabel asked. "We need to strengthen government's role in monitoring those facilities and to adequately fund facilities so they can have well-trained staff."

Health department officials said on their investigators' last visit to Santa Rosa, on Feb. 28, the home was "in substantial compliance" with state rules.

"It signifies that there is no potential for harm and that the facility is substantially doing what the regulations ask," said Tim Chafey, a registered nurse and investigator with the health department's Tucson Office of Long Term Care.

The state health department received three complaints in October and November about the way the woman was being treated at Santa Rosa, at 1650 N. Santa Rosa Ave., near East Pima Street and North Swan Road. But it was not until the the third complaint, on Nov. 13, that the woman's situation warranted a "Priority One" response, Chafey said.

That means a patient has been harmed, or there is "extreme potential" for additional harm, Chafey said. State investigators must visit the facility within two days, he said.

Health investigators went to the home on Nov. 15 and found the staff had done little to prevent the woman from falling repeatedly. For example, she fell six times from Oct. 7 to 26, but "care conference" reports from Oct. 23 and Nov. 2 contained no evidence that her falls were discussed.

On Nov. 12, the woman was assessed and found to be at high risk for falls. On Nov. 20, a lower bed was ordered, the state's report shows.

In addition, investigators found the woman had not received four doses of a medication prescribed by her doctor to control her diabetes, and had missed two doses of a pill used in patients with high blood pressure and heart disease.

And from Oct. 1 through Oct. 15, the woman was not given 22 doses of phenergan, a drug used in patients with schizophrenia to relieve anxiety. Patient care reports dated Oct. 23 and Nov. 2 did not mention the missed doses, or any attempt to deal with the woman's extreme behavior.

When a patient's behavior problems change or escalate, "one of the first things you want to do is see if medications have been missed," said Lisa Wynn, the health department's deputy assistant director.

Santa Rosa staff did not make that check, or failed to document it.

But the four "missed" doses of the diabetes drug Glipizide were not given to the patient because her blood sugar was below the level at which she required the drug, Santa Rosa stated in its correction plan required by the state. But the home said it has started a new procedure for properly documenting when medications are not given, and why.

Last week's $1,500 fine was the second penalty Santa Rosa has paid since Oct. 31. The home paid $3,500 after a March 2006 complaint investigation documented that a male nurse and two other staffers were verbally, emotionally and physically abusive to seven residents.

One of the residents was kicked, another was restrained with a choke hold, another had his arm twisted behind his back, and several of the residents said staff members had yelled at them.

A female resident began weeping and shaking as she described to state investigators the time the male nurse twisted a resident's arm behind his back — all because the resident wanted to wear a hat in the dining room, the state's report says.

"No one should be treated that way. These people are my friends," the woman told investigators.

The seven-month interval between the health department's investigation and the fine reflects the fact that at least one of the employees was fired and the abuse stopped during the health department's investigation.

The Arizona Department of Health Services enforcement team decided to fine Santa Rosa $500 for one of the 19 days when staff members failed to give the female resident at least one medication dose. It also agreed to penalize the home $250 a day for each of the four days the home waited to send the woman to an emergency room after her Sept. 26 fall that left her bruised and lacerated.

The fine could have been higher, but the state found no other instances of patients missing medications or staffers failing to respond to falls, Wynn said.

The purpose of a fine is "to create enough incentive to stay in compliance (with state licensing rules) but to not be so detrimental to the facility as to pull too many resources away from patient care," Wynn said.

Grabel said he thought the penalty was low, "considering what happened to the patient … If the individual had nine falls, there should have been a fall-prevention plan that was implemented for her. If there was a problem with her getting her meds appropriately, then that also should have been taken care of as part of a plan. We need to make sure that we have better care for our elderly."

● Contact reporter Jane Erikson at 573-4118 or jerikson@azstarnet.com.