4432 James Ave Castro Valley, CA 94546
Citation Number: 020009728
Citation Date: 02/04/2013
Violation Date: 7/18/12
Class: AA
Penalty: $60,000.00

F323 - The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.

The facility failed to follow the aforementioned regulation when it failed to provide one (1) of three sampled residents, 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 a history of choking on foods. Certified Nursing Assistant (CNA) 1 and Activities Assistant (AA) accompanied Residents 1, 2, and 3 to a baseball game. The facility failed to assure that CNA 1 and AA knew that Resident 1 was to have a mechanical soft (soft chopped, blended or ground food, mechanically altered to make it easier to chew and swallow) diet. During the ball game, the staff bought the three residents hot dogs for lunch. While Resident 1 was eating his hot dog on a bun, he began to choke. Facility and ball park staff attempted to clear the hot dog from Resident 1's airway. The resident lost consciousness was taken to a hospital, where he died. The failure to provide Resident 1 with his prescribed diet resulted in his choking incident and death.


Review of the clinical record on 9/21/12 at 9:30 a.m., showed that Resident 1 was a 92 year old male, admitted to the facility on 1/26/12 with diagnoses including dysphagia, (difficulty swallowing) and muscle weakness.

Record review on 9/21/12, of the Minimum data Set (MDS) dated 7/18/12, showed that Resident 1 required assistance in setting up his meals.

The Physician Admission Orders, dated 1/25/12, included an order for a pureed, (blended to a smooth consistency) 2000 calorie, diabetic diet.

A Physician order, dated 2/6/12 showed, "Change diet to NCS (no concentrated sweets) Puree thin liquids secondary to poor mastication (chewing) of food.

A Physician order dated 2/10/12 changed the diet to Mechanical soft, ground meat with extra gravy, no crust on breads; thin liquids (NCS).

The "Therapy Progress Documentation" form, dated 2/10/12 reflected that Resident 1 reported a choking incident that occurred on 2/9/12, while eating a sandwich with crust for dinner. The therapist documented that he, "Tolerated a small amount of his mechanical soft lunch tray today with lengthy mastication but no overt signs or symptoms of aspiration (accidental inhalation of food or liquids into bronchi or lungs) noted. Patient able to (I) detail his swallow precautions. Changing diet to Mechanical Soft, ground meat with thin liquid- No crust."

A physician order, dated 3/13/12, reflected that Resident 1 could go out of the facility on outings with his responsible party, and on facility outings.

Care plans dated 1/28/12, and 5/1/12 for, "Potential for Constipation", showed Resident 1 was identified with "Swallowing problems." Care Plans for "Nutritional Status" dated 2/9/12, and 5/21/12 reflected that Resident 1 had swallowing problems.

Review of "Interdisciplinary Team Conference Notes" dated 5/1/12 included Physician's orders, Diagnosis, Care Plan, MDS/Assessments. The Summary portion of the Interdisciplinary Team Conference Notes, Dietary section indicated, "Resident is on mechanical soft NCS diet with ground meat."

Physician's Orders for 7/1/2012 to 7/31/2012 continued the Mechanical soft, NCS, Ground Meat with extra gravy, no crust on breads, thin liquids diet, and directed staff to check Resident 1's tray for accuracy, each Saturday.

A nurses note, dated 7/18/12, reflected that Resident 1 was excited about going to a ball game that day. The 7/18/12 nurses note for 4 p.m., reflected that the assistant activities director called the facility at 3:30 p.m., to report that Resident 1 was choking, and losing consciousness. An entry at 4:30 p.m., reflected that Resident 1 was admitted to the hospital.

In an interview on 7/20/12, at 5 p.m., the Administrator stated that Resident 1 was in the hospital intensive care unit, on a ventilator (mechanical breathing machine).

During an interview on 9/21/12, at 9:30 a.m., the Administrator stated that when residents went out on pass, no medical information was sent with them. He stated that the facility sent, "Contact info" with residents who went out of the facility for outings. The Administrator further stated, "We have taken measures so this won't happen again."

In an interview on 9/21/12, at 13:30 p.m., the Director of Nursing stated that the staff should have been aware of Resident 1's current diet, but, "Obviously they did not, or they wouldn't have given him a hot dog." The DON also stated that the staff did not have any records with them on the outing, except, "Contact info."

During an interview with AA, on 10/4/12 at 10 a.m., she stated she did not know if Resident 1 had a history of choking. When asked if she knew what type of diet Resident 1 was on at the time of the 7/18/12 choking incident, she stated that she did not know. When asked if she knew whether an uncut hot dog on a bun was allowed according to Resident 1's diet order, she stated she did not know. AA stated that she and CNA 1 tried the Heimlich maneuver, and a man tried, but nothing came out.

During an interview with Certified Nursing Assistant (CNA) 1 on 10/4/12 at 10:30 a.m., she stated that she did not have information about the residents' diets, medications, or special precautions when she took Residents 1, 2, and 3 to the ball game. She stated she did not know if Resident 1 had a history of choking. When asked if she knew what type of diet Resident 1 was on at the time of the 7/18/12 choking incident, she stated that she did not know. When asked if she knew if eating an uncut hot dog on a bun was allowed according to Resident 1's diet order, she stated she did not know.

In an interview with the DON (Director of Nurses), on 10/11/12, at 10 a.m., she stated that Resident 1's daughter called the facility to report that he died at the hospital on 7/28/12. DON stated that prior to Resident 1's choking incident, the facility did not have a policy or procedure for residents going out of the facility. She stated that the practice was to notify the responsible parties that their resident was going on an outing. The DON stated that, as a result of Resident 1's incident, the facility developed an information form, to be filled in when a resident goes on an outing.

Review on 11/28/12, of the, Coroner Investigator's Report, dated 7/30/12 at 4:29p.m., showed, "Preliminary Summary- Accidental death of a 92 year old male at San Leandro Hospital. On 7/18/12, the decedent choked on a hot dog at a baseball game. Paramedics responded, partially removed a food bolus and transported to the ER (Emergency Room). Additional food bolus was removed in the emergency (room) and he was transferred to the ICU. His condition deteriorated (anoxic brain injury due to asphyxia)( air way blocked) and death was pronounced .... Cause of Death, A- Anoxic (lack of oxygen) Brain Injury, B-Aspiration of Food Material."

The coroner's Medical Summary reflected, "According to (The Hospital) medical records, (Resident 1) was admitted to the hospital for respiratory arrest secondary to food aspiration with an anoxic brain injury on July 18, 2012. He was at a baseball game when he started choking on a hot dog. A bolus was removed by paramedics, he was transported to the hospital, and more of the bolus was removed by doctors in the emergency room."

The coroner's, "Description of the Death/Injury Scene" reflected, "The decedent died as an in-patient at San Leandro Hospital - ICU. The decedent choked on a hot dog at the Oakland Coliseum during a baseball game."

Failure by facility staff to ensure that Resident 1's dietary restrictions were followed while on a facility outing resulted in an imminent danger of death or serious harm to the resident.