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Deaths tied to staff misconduct in California nursing homes are often penalized far too lightly, a report released Monday claims. Penalties are frequently issued at level not “fitting” the severity of the incident, authors write.

The report, issued by Disability Rights California, included an analysis of cases in which the California Department of Public Health, Licensing and Certification Division issued lower level penalties for incidents where staff conduct reportedly contributed to a resident’s death.

The cases included were issued Class A citations and lower monetary penalties after CDPH ruled that staff negligence did not play a factor in the residents’ deaths — a decision that “fails to accurately alert the public about the severity of resulting harm to residents in the long-term care facilities in which they entrust their loved ones,” the report’s authors allege.

“We analyzed hundreds of cases and found that negligent care directly contributed to resident deaths,” said Pamila Lew, an attorney with DRC. “But the state issued lower level citations, which resulted in lighter penalties, sometimes seeming to significantly undervalue staff responsibility in the loss of life.”

The report found that CDPH did not consistently apply citations of the same level when staff misconduct contributed to a resident’s death. The agency also does not employ consistent standards for issuing citations following resident deaths, DRC claims.

The group recommends that the state issue Class AA citation when staff conduct is a direct cause of a resident’s death, and that the agency apply consistent standards for issuing citations. DRC also called on health officials to be more transparent with the facts surrounding resident death cases, and increase the penalty amount for resident deaths that were indirectly caused by staff conduct, or was one of multiple causes.

CDPH reviewed the group’s report and agreed to publish more information on resident deaths and nursing home citations on its website. DRC is also pushing for a new citation classification when incidents result in a resident’s death.