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CPMC East Campus Resident Dies a Nightmare Death

    An 88 year old resident admitted following hip surgery was noted to have a poor appetite and lost over 21 pounds in the two weeks after her admission. She had irregular bowel movements and began to exhibit nausea and abdominal distention. The resident's family indicated that the resident's stomach had grown so large it appeared she was pregnant. A daughter reported she “begged the staff to do something for her mother but nothing was done.” The medical records showed no accurate and comprehensive assessment of the resident’s significant change in bowel patterns.


    On 2/15/12, the resident began vomiting "copious amounts of dark-brown fecal-smelling fluid from her mouth and nose" exceeding 1000 milliliters. A nurse reported “it was like a faucet, just continuous fluid coming out of her mouth and nose.” The patient lost consciousness. CPR was started and additional fluid would come from the resident’s mouth and nose every time she was given a chest compression. The resident died from aspirating her vomit.


    The facility was cited for failing to follow its policy to assess and review significant changes in condition, plan care appropriately, or document physician notifications regarding resident changes in condition. The Department of Public Health issued one low "D-level" federal deficiency against the facility - indicating there was no harm - and one state "B" citation with a fine for $2,000.


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