An 80-year-old dementia patient fell from his bed and died at Valley Convalescent Hospital in February, something a state public health investigation determined this month came as a direct result of poor care at that facility.

The hospital has been fined $100,000 and received a “Class AA Citation,” the most severe penalty under state law, the California Department of Public Health announced Wednesday morning. If the facility incurs another Class AA Citation in a two-year period, it could risk losing its license.

Romulo Lomibao, the hospital administrator who oversees the 87-bed facility that cares for those recuperating from illnesses and operations, wouldn’t comment to The Californian other than to say the investigation had “been lifted and cleared,” before hanging up on a reporter. Investigation reports confirm the facility has come into compliance by ensuring all beds have working guard rails.

The patient fell Feb. 21, after a certified nursing assistant repositioned him in his bed, but didn’t ensure a guard rail was up, according to a state investigation report.

That man’s roommate said he saw him roll out of bed at about 4 p.m.

“I was watching TV when I heard him yell, ‘I’m falling, I’m falling,’” his roommate said. “All I can say is when he fell, the side rails were down. I saw it clearly.”

The result of the fall? A fracture in the “second cervical vertebrae just below the skull that protects the spinal cord,” the report states. He stayed at a local hospital for about a week, then returned to Valley Convalescent Hospital Feb. 28, where he died the next day.

His medical records suggest the cause of death was a fracture, a cardiovascular accident and dementia, but CDPH determined it was a direct result of his fall.

“The violation presented either an imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result, and was a direct proximate cause of death of the resident,” the report states.

It’s not the first time Valley Convalescent Hospital has been fined by the CDPH, or had patients complain about falls.

Since 2012, the agency has recorded nine complaints of patients falling, eight of which were self-reported. It’s unclear how or where they fell because CDPH does not provide detailed information about the complaints.

CDPH has taken action against Valley Convalescent Hospital 15 times since 2006, fining it as much as $20,000 in 2007, state records show. In total, the facility has been fined more than $160,000 since 2003. Just this year, it has received eight complaints, self-reported seven incidents and CDPH has found 28 deficiencies.

Of the seven self-reported incidents, three included patient abuse. Two of those were between residents, however one included an employee abusing a patient, records show.

It’s not typical for the CDPH to hand down a penalty as severe as the Class AA Citation, said Leslie Morrison, director of investigations at the Disability Rights California, a statewide advocacy organization that has researched state penalties against nursing homes and lobbied for more consistency in the process.

That’s because the threshold to prove a “direct proximate cause of death” is exceedingly high, Morrison said. Her agency reviewed thousands of penalties handed down by the CDPH between 2000 and 2014 and found that in many cases, there’s little difference between what constitutes a Class A citation and the more severe Class AA citation.

“The department is not always able to issue that level of citation in the case of deaths that, in our opinion, the conduct of the staff was the direct cause of the individual’s death,” Morrison said. “It’s tragic that you have someone who’s died and that the death was directly caused by the facility, but if that’s the case, we’re glad to see the department issuing a citation at the maximum level they could.”

Harold Pierce covers education and health for The Californian. He can be reached at 661-395-7404. Follow him on Twitter @RoldyPierce

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