MORTON BAKAR CENTER
494 Blossom Way Hayward, Ca 94541
Citation Number: 020009084
Citation Date: 3/12/12
Violation Date: 9/6/11
Class: AA
Penalty: $60,000.00

CLASS AA CITATION-- PATIENT CARE

F325: CFR 483.25 (i) Nutrition

Based on a resident's comprehensive assessment, the facility must ensure that a resident- 483.25(i) (2) Receives a therapeutic diet when there is a nutritional problem. The facility violated the aforementioned regulation by failing to provide the therapeutic diet ordered by the physician to ensure that Resident 1 was not given a food that was unsafe to eat. Resident 1 had no teeth, and a history of choking on foods. A facility staff person gave Resident 1 a cold cheese sandwich that was not suitable for the therapeutic diet. As a result, Resident 1 choked on the cheese sandwich, was unable to breathe and her heart stopped. Resident 1 did not recover from the incident, and she died.

Review of the clinical record, on 9/29/11, showed that the facility re-admitted Resident 1, a 66 year old, on 10/15/09. Resident 1 had multiple medical diagnoses that included a history of aspiration pneumonia (a lung and airway infection caused by inhalation of foreign material, usually food, liquid, and/or vomitus).

A Licensed Nurse (LVN 1) recorded information about Resident 1's mouth condition on the "Nursing Oral/Dental Assessment," document, dated 10/15/09. According to the record, Resident 1 had no teeth. Review of the Physician's Orders, for the care of Resident 1, that were current for the month of September 2011, showed that Physician 2 instructed the facility to give Resident 1 a Mechanical Soft Diet (diet of modified texture that enables easier swallowing and decreases the risk of choking by changing the texture of foods to soft, chopped or ground).

The facility's plan of care for Resident 1, most recently updated on 7/25/11, contained instructions to care for Resident 1's nutritional needs. According to the care plan, Resident 1 had chewing difficulty and the facility was to provide a therapeutic, mechanical soft texture diet.

According to the Minimum Data Set (an assessment of residents' health status), dated 9/6/11, Resident 1 needed supervision for decisions due to poor decision making. A review of the facility's kitchen snack plans, for 7 p.m. daily, showed that Resident 1 was to receive a mechanical soft consistency, "Fruit," snack. Nurses' notes, dated 9/6/11 at 7:40 p.m., reflected that Resident 1 was, "Eating snacks," at the nurses' station. A staff person, who was not a licensed nurse, called out to licensed staff that Resident 1 was, "Choking." Resident 1 was unable to talk and had food in her mouth. Resident 1 lost consciousness and facility staff began CPR (cardiopulmonary resuscitation) and called 911.

Review of EMP (Emergency Medical Personnel) records, dated 9/6/11, showed that at the time of the arrival of the EMPs, 7:41 p.m., Resident 1 was not breathing and her heart was not beating. EMPs found Resident 1's airway obstruction was, "Complete." EMPs used a long, special tool to remove food from Resident 1 's airway and used suction to clear her airway. The record reflected, "Patient has large amount of food in airway." Resident 1 was rushed to the nearest hospital for emergency care as EMPs provided CPR.

According to the Admission History and Physical, dated 9/6/11, upon arrival at the hospital emergency department (ED), Resident 1's heart was beating but she did not breathe on her own. Resident 1 did not respond when spoken to and did not open her eyes. At the time of admission to the hospital from the ED, Physician 3 documented that Resident 1 was, "Comatose on ventilator" (Resident 1 did not breathe without a machine). Resident 1, "Had a very low probability of survival following her massive arrest."

A summary of Resident 1's neurological status was dated 9/7/11. According to Neurologist 1, Resident 1 was, "Deeply comatose." Her brain had been severely damaged due to a lack of oxygen. Resident 1 did not respond to verbal or painful stimulus. "(Resident 1's) outlook and survival expectancy is dismal." Resident 1 did not regain consciousness and did not regain the ability to breathe without a machine. The machine supported breathing was discontinued on 9/11/11 and Resident 1 died.

In an interview, on 9/29/11 at 2:08p.m., regarding the evening snacks that were provided to facility residents, Cook 1 stated that the evening snack cheese sandwiches were not grilled to soften the cheese. On 9/29/11 at 3:40 p.m., Certified Nurse Aide (CNA) 1 stated that EMP (Emergency Medical Personnel) took out a big piece of cheese sandwich from Resident 1's throat. CNA 1 stated that they showed the piece of sandwich to the facility staff, and that it was approximately a one inch by one inch square piece of cheese sandwich. During an interview, on 9/29/11 at 4:05p.m., LVN 2 stated that, on 9/6/11 CNA 2 called to him saying Resident 1 was choking. LVN 2 stated that he saw a piece of sandwich bread in Resident 1's right hand.

During an interview on 10/3/11 at 12:37 p.m., CNA 3 stated that the kitchen staff put extra cheese sandwiches (not assigned to a particular resident) on the snack cart along with the residents' prescribed snacks. CNA 3 stated that she gave half of a cheese sandwich to Resident 1, and did not stay with Resident 1 while she ate. CNA 3 also stated that she did not check with the Licensed Nurse before giving the sandwich to Resident 1. She stated that the Administrator told her she should have asked the Licensed Nurse, before giving any food to Resident 1.

In an interview, on 10/11/11 at 9:36a.m., FSW 1 (Food Service Worker) stated that the half cheese sandwiches sent out on the cart as extra snacks in the evening were prepared using bread, mayonnaise, and a cold slice of yellow American cheese. The half sandwiches were prepared and served cold with no grilling/cooking and with no texture alteration.

In a telephone interview and concurrent record review of the facility's dietary manual's definition of what was allowable for someone on a Mechanical Soft Diet, on 10/11/11 at 10:10 a.m., the RD (Registered Dietician) stated that an American cheese sandwich, that was not grilled to soften the cheese, was not to be given to someone on a Mechanical Soft diet. The cheese slice would be too hard to chew. On 10/11/11 at 10:38 a.m., in an interview, the ADON (Assistant Director of Nurses) confirmed that Resident 1 had no teeth, no dentures, and had a history of choking. ADON stated that Resident 1 was on a Mechanical Soft diet because she had no teeth to chew her food.

In a concurrent interview and record review, on 10/11/11 at 11 a.m., Physician 1 stated she had seen Resident 1 earlier that day, on 9/6/11, and she (Resident 1) had looked great, was interactive and talkative. In an interview, on 2/1/12 at 1:44 p.m., the Medical Director stated that the way the facility ensured that residents received the appropriate snack for their diet was by using labels that were pre-selected according to their diet cards and physician orders. If the resident wanted a substitute or extra food for their snack, the Medical Director stated that he depended on the Licensed Nurses to know what would be appropriate for that resident.

In an interview, on 2/1/12 at 1:46 p.m., the ADON confirmed that the Certified Nurse Aides should check with the Licensed Nurses to see if the snack or extra food that the resident requested was appropriate for the resident's prescribed diet. In an interview, on 2/1/12 at 1:50 p.m., the DSS (Dietary Services Supervisor) stated that the snack labels printed from the computer were updated whenever there was a change in the physician's orders. The snack labels listed the resident's intended snack for that day that was in accordance with the ordered diet. DSS explained that every day the kitchen prepared the prescribed snacks as well as extra snacks for any new admission or for residents who were hungry during the night. These extra snacks were made according to regular diet specifications (no alteration to the texture/consistency of the food). The prescribed snacks and extra snacks were placed on two carts (one cart per nursing station).

In an interview, on 2/1/12 at 1:53 p.m., the ADON (Assistant Director of Nurses) stated that CNAs (Certified Nurse Aides) would then pick up the carts and distribute the prescribed snacks to the residents. The ADON explained that the facility's procedure was that if a resident would ask for extra food or a different snack than the one prescribed by their physician, the Certified Nurse Aide would check with the Licensed Nurse if the snack requested was appropriate for the diet prescribed for the resident . In an interview, on 2/1/12 at 2:01 p.m., the Medical Director stated that Resident 1 was not medically competent to make her own treatment decisions. Resident 1 had a history of impulsive behavior and poor judgment.

In an interview on 2/1/12 at 2:06 p.m., the ADON stated that the Certified Nurse Aide should have gone to the Licensed Nurse to ask regarding Resident 1's extra food/snack request since Resident 1 had a history of swallowing problems and because of Resident 1's specific diet orders.

Therefore, facility staff gave Resident 1 a cold cheese sandwich that was not appropriate for the therapeutic diet, a mechanical soft diet. Resident 1 could not safely eat the sandwich. Resident 1 died as a result of choking on the food that she should not have been given to eat.

These violations 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 the death of the patient.