ENGLISH OAKS CONVALESCENT & REHABILITATION HOSPITAL
2633 WEST RUMBLE RD, MODESTO, CA 95350
Citation Number: 030004672
Citation Date: 2/8/2008
Violation Date: 2/17/2007
Class: AA
Penalty: $ 100000.0

72311-Nursing Service-General (a)Nursing services shall include, but not be limited to, the following: (1)Planning of patient care, which shall include at least the following: (A)Identification of care needs based upon an initial written and continuing assessment of the patient's needs with input, as necessary, from health professionals involved in the care of the patient. Initial assessments shall commence at the time of admission of the patient and be completed within seven days after admission.

72523-Patient Care Policies and Procedures (a)Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. (2)Nursing services policies and procedures which include: (A)A current nursing procedure manual

The following citation was written as a result of an unannounced visit to the facility on 03/02/07 for the investigation of complaint #CA000107530.

The Department determined the facility failed to: 1. Identify Patient A's care needs while he was choking. 2. Provide emergency care and services to Patient A after he choked. 3. Implement and follow the facility policy and procedure for "Choking-Heimlich Maneuver", (undated).

These failures resulted in the death of Patient A due to asphyxiation following an obstruction of the airway by a food bolus.

Patient A was a 91 year old male admitted to the facility on 01/06/06 with medical diagnoses including elevated blood pressure, renal insufficiency, congestive heart failure and pulmonary congestive hypostasis (the accumulation of fluid in the lungs).

A Minimum Data Set, dated 12/04/06, documented Patient A had some short and long term memory deficits and moderately impaired cognition. Patient A was usually understood by staff and usually understood others. Patient A required staff assistance with his activities of daily living. Patient A was highly involved with eating but received help from staff during meals. A Resident Risk Assessment, dated 01/10/06, documented Patient A was slow to respond, fed himself slowly and ate between 25-50% of most meals.

A Dietary Nutritional Assessment, dated 01/13/06, indicated Patient A wore dentures without difficulty and did not have a chewing or swallowing problem. The Registered Dietician's (RD) Progress Note, dated 01/17/06, documented Patient A requested a mechanical soft diet. An Annual Nutritional Assessment, dated 04/11/06, documented Patient A was receiving a mechanical soft low salt diet. In the comment section of the assessment the RD noted Patient A was on a mechanical soft diet due to "problems with chewing (poor dental)." An Annual Nutritional Assessment, dated 02/12/07, documented Patient A continued to eat a "soft" diet, did not have any swallowing problems and was assisted with his meals. An RD note in the "comment" section of the form documented Patient A "does not want peaches."

Physician's Orders, dated 01/01/07, and signed by Patient A's physician, documented the following: 1. Patient A was to receive oxygen at 2 liters per minute via nasal cannula, as needed, if his oxygen saturation was at 90% or less 2. Patient A was to receive a low salt mechanical soft diet

The Medication Administration Record (MAR) for February 2007 was reviewed. One of the medications Patient A was to receive was oxygen at 2 liters per minute via nasal cannula, as needed, if his oxygen saturation was 90% or less. There were no nursing initials or documentation indicating Patient A received any oxygen during the month of February 2007.

Nursing Notes, dated 02/17/07 at 7:45 a.m. completed by LVN 1, documented the nurse was "Called to patient to assess his swallowing by CNA, upon assessment mouth clear O food [no food] present in mouth, Pt [patient] was swallowing a few times". The nurse told the CNA to take Patient A back to his room to be "laid down".

Nursing Notes, dated 02/17/07 at 7:50 a.m. completed by LVN 2, documented Patient A was "Brought back from dinning hall is alert resp [respirations] even was swallowing something, there was no food in his mouth. He was trying to cough out something said he is 'ok' when this nurse ask him if something wrong with him. Try to get his O2 stat [saturation] got his pulse was 67 on pulse oxymeter & there was change in his condition he became unresponsive. Call RN Supervisor. Stat [quickly] to the room we kept him in his w/c [wheelchair] to keep him in upright position to facilitate swallowing".

Nursing Notes, dated 02/17/07 at 7:55 a.m. completed by the RN Supervisor (RN 1), documented "Called to RM [room] 106B by L.V.N. to assess unresponsive pt. [patient]. Upon arrival to room, found pt. [patient] sitting up in w/c [wheelchair]. O [no] response to tactile stimuli. Resp. [respirations] 36 & labored, good air movement on auscultation. Mouth open, nothing visible in mouth upon exam. CNA obtaining vs [vital signs]. Came to Nurse's station, '911' called".

Nursing Notes, dated 02/17/07 at 8:05 a.m. completed by RN 1, documented "Called back to room by CNA, O [no] pulse, O resp [no respirations], O B/P [no blood pressure]. Pt. [patient] is DNR [do not resuscitate]. AMR called, ambulance cancelled. Coroner, daughter & son & MD notified via phone".

There was no nursing documentation regarding emergency nursing services provided to Patient A. There was no documentation indicating the paramedics arrived at the facility and began providing Patient A with emergency care.

An interview was conducted with the Deputy Coroner on 03/16/07 at 9:45 a.m. The Deputy Coroner stated Patient A's cause of death was determined from an autopsy conducted on 02/20/07. The Deputy Coroner indicated Patient A's cause of death was from a pitted peach located in his oropharynx (the portion of the tube that extends from the esophagus up to the base of the skull) near the opening of the larynx (the organ responsible for the production of sounds and serves as an air passage way to the lungs). The Deputy Coroner stated Patient A was unable to get any air into his lungs because of the location of the peach. The Deputy Coroner stated the facility had placed a portion of a peach in a small plastic container which was delivered to the Coroner's Office with Patient A's body.

An interview was conducted with the Director of Nursing (DON) on 03/23/07 at 10:00 a.m. The DON stated she had received a telephone call from the Charge Nurse (RN 1) on 02/17/07 to report that Patient A had died. The DON stated RN 1 reported that Patient A "might have choked" while he was eating breakfast. The DON indicated RN 1 assessed Patient A and called "911" to report an emergency. The DON stated RN 1 cancelled the ambulance after Patient A became non-responsive. The DON indicated Patient A had a physician order for "Do Not Resuscitate" (DNR). The DON stated the paramedics arrived at the facility before receiving the cancellation notice and had begun cardio-pulmonary resuscitation after staff had reported Patient A had choked on something. The DON indicated RN 1 informed the paramedics that Patient A was a "DNR" and had all resuscitation efforts stopped. The DON stated the paramedics notified the Modesto Police Department after being told to stop all resuscitation efforts.

The DON stated Patient A was a "poor" eater. The DON explained that Patient A was usually able to feed himself but he ate very slowly and did not complete his meals. The DON explained that staff would sit with Patient A and help him if he needed it but usually only encouraged him to eat more of his meal. The DON stated Patient A would usually eat more if staff was with him. The DON indicated Patient A did not have difficulty cutting up soft food items and he was on a mechanically soft diet.

An interview was conducted with LVN 1 on 03/23/07 at 10:30 a.m. LVN 1 stated a Certified Nursing Assistant (CNA) and Restorative Nursing Assistant (RNA 1) reported to her that Patient A was choking on something while she was in the dining room giving other patients their medications. LVN 1 stated she checked Patient A and he was breathing but sounded "a little raspy" when he spoke. LVN 1 stated Patient A told her he wanted to take out his dentures. LVN 1 indicated Patient A took out his dentures. LVN 1 stated she did not take Patient A's vital signs or provide him with any oxygen. LVN 1 stated it did not look like Patient A had eaten very much but most of his milk was gone. LVN 1 indicated Patient A might have choked while drinking his milk. LVN 1 stated she instructed RNA 1 to take Patient A back to his room and inform his nurse about his status. LVN 1 indicated RNA 1 took Patient A out of the dining room in his wheelchair. LVN 1 stated she did not speak to Patient A's nurse about his condition at that time.

An interview was conducted with LVN 2 on 03/23/07 at 10:40 a.m. LVN 2 stated she was in charge of Patient A's care on 02/17/07. LVN 2 stated she was not in the dining room and did not know what had happened to Patient A while he was eating his breakfast. LVN 2 indicated RNA 1 brought Patient A to the Nurse's Station and reported he was not breathing well. LVN 2 went with RNA 1 and Patient A into his room. LVN 2 indicated she heard "some gurgling" in the back of Patient A's throat and asked him if he was alright. LVN 2 stated Patient A told her he was "OK". LVN 2 stated while Patient A was in his wheelchair she wanted to check his pulse oximetry (a device attached to a finger that indicates an individual's pulse and amount of oxygen saturation in the blood). LVN 2 indicated she was able to get a pulse reading off of the pulse oximetry device but was unable to get an oxygen reading (Patient A's oxygen saturation was not obtained). LVN 2 stated while she was taking the reading Patient A became non-responsive but he was still breathing and his color was "normal." LVN 2 stated she had RNA 1 call RN 1 to the room. LVN 2 stated when RN 1 came to the room she listened to his lungs and instructed staff to put Patient A into his bed. LVN 2 stated she left Patient A's room to check his Advance Directive (instructions given to staff for the care during emergencies or a change of condition). LVN 2 stated RN 1 followed her out of Patient A's room and telephoned "911." LVN 2 stated RN 1 was called back into the room after telephoning for emergency services. LVN 2 stated she did not go back into Patient A's room at that time. LVN 2 stated she did not speak with the paramedics when they arrived in Patient A's room.

LVN 2 stated she did not place Patient A on any oxygen or attempt a Heimlich Maneuver (a method of forcing out food or some other substance that has entered the trachea instead of the esophagus). LVN 2 stated Patient A was able to speak and was breathing.

An interview was conducted with RN 1 on 03/24/07 at 10:30 a.m. RN 1 stated she was asked by LVN 2 to assess Patient A because he might have choked on something and he was having difficulty breathing. RN 1 stated Patient A was sitting in his wheelchair when she entered his room. RN 1 indicated Patient A had good air movement but his breathing was labored. RN 1 stated she left Patient A's room and called "911" for emergency medical services and then called the DON to report Patient A's condition. RN 1 stated while she was calling the DON, staff called her back into Patient A's room because he was not breathing and did not have a pulse. RN 1 stated she called the ambulance company back to cancel the "911" call because Patient A was a "DNR" but the paramedics arrived before the cancellation was made. RN 1 indicated the paramedics had hooked Patient A up to their monitors. RN 1 stated Patient A did not have a pulse and she informed the paramedics that Patient A was a do not resuscitate patient. The paramedics stopped all resuscitation efforts.

RN 1 stated staff showed her a piece of peach "that came up while they moved him to the bed." RN 1 stated she instructed LVN 3 to place the piece of peach in a denture cup and set the cup on the bedside table. RN 1 stated the paramedics telephoned the police department after finding out Patient A had been choking.

RN 1 did not remember if anyone placed Patient A on oxygen or attempted a Heimlich Maneuver. RN 1 stated she did not place Patient A on any oxygen or attempt a Heimlich Maneuver.

An interview was conducted with LVN 3 on 03/24/07 at 11:30 a.m. LVN 3 stated she went into Patient A's room to help staff after being told Patient A was having difficulty breathing. LVN 3 stated when she walked into the room Patient A was in his wheelchair and she thought he was "already" dead. LVN 3 stated she had two staff members assist her in moving Patient A into his bed. LVN 3 stated after moving Patient A to his bed she noticed "that thing" in his mouth. LVN 3 indicated she thought it was mucous and got a glove to remove it from Patient A's mouth but when she moved the "glob" it was in fact a piece of peach. LVN 3 stated the peach "must have come up" while they were moving him to his bed.

LVN 3 stated Patient A was not on oxygen and his hands were a deep purple color when she entered the room. LVN 3 stated Patient A "was gone" before he was moved to his bed. LVN 3 stated the paramedics arrived after Patient A was returned to his bed. LVN 3 indicated the paramedics began resuscitation efforts but stopped after being told by the RN that Patient A was a "DNR".

An interview was conducted with RNA 1 on 07/24/07 at 10:45 a.m. RNA 1 stated she was in the dining room the morning of 02/17/07 while Patient A was being fed. RNA 1 indicated another CNA was assisting Patient A with eating. RNA 1 stated she noticed the CNA patting Patient A on the back and went to help. RNA 1 stated Patient A had his hands "up around his throat". RNA 1 stated she asked Patient A if he could talk and he replied "I can't" in a very hushed voice. RNA 1 stated she asked Patient A if he was choking and he said "Yes". RNA 1 stated she called LVN 1 over to check Patient A. RNA 1 indicated that when LVN 1 arrived she noticed a carton of milk on the table and thought Patient A might have choked on the milk. RNA 1 stated both she and LVN 1 were trying to encourage Patient A to cough. RNA 1 stated Patient A said "dentures" and LVN 1 told him to take his dentures out. RNA 1 stated she looked into Patient A's mouth and did not see anything. RNA 1 stated LVN 1 told her to take Patient A to the Nurse's Station and notify Patient A's Charge Nurse (LVN 2). RNA 1 stated she pushed Patient A in his wheelchair to the Nurse's Station and notified the Charge Nurse (LVN 2). RNA 1 stated while taking Patient A to the Nurse's Station she advised Patient A to put his hands up because he was short of breath. RNA 1 indicated Patient A put both his hands up into the air. RNA 1 stated when she arrived at the Nurse's Station she reported to LVN 2. LVN 2 began checking Patient A. RNA 1 stated when they first arrived at the Nurse's Station Patient A was breathing and able to speak then he lost consciousness and LVN 2 contacted RN 1. RNA 1 stated she was paged to another area of the facility while LVN 2 was calling RN 1. Another CNA (CNA 1) was assisting her and LVN 2 so she left to complete her work. RNA 1 stated Patient A was not placed on oxygen while she was with him and no other emergency care was provided while she was with him. RNA 1 stated she assisted with Patient A "for about ten minutes".

An interview was conducted with Paramedic 1 on 07/23/07 at 9:30 a.m. Paramedic 1 stated he and a team mate responded to an emergency call received from Emergency Dispatch ("911") of a patient having difficulty breathing. Paramedic 1 stated when he entered Patient A's room Patient A was lying in a bed in a semi-fowlers (the head of the bed was up approximately 30 degrees) position. Paramedic 1 stated there was "some type" of food wrapped up in a napkin or paper towel next to Patient A's bed on the over-bed table. Paramedic 1 stated there was a CNA in the room with Patient A and he asked the CNA if Patient A was breathing. Paramedic 1 stated the CNA was unsure if Patient A was breathing so he began to examine Patient A. Paramedic 1 stated he discovered Patient A was not breathing and began to attach the emergency monitors to Patient A and prepare for intubation (a procedure that introduces a tube into the airway to provide mechanical breathing). Paramedic 1 stated the monitor indicated Patient A was in asystole (his heart was not beating) but before he could begin resuscitation efforts the RN entered the room and told him the emergency call had been cancelled because Patient A was a "DNR" (do not resuscitate).

Paramedic 1 stated he stopped all resuscitation efforts and walked out to the Nurse's Station to obtain statistical information pertaining to Patient A. Paramedic 1 stated while at the Nurse's Station he was informed that Patient A had in fact choked and a portion of food was found in Patient A's mouth. Paramedic 1 stated because Patient A had choked and the RN had informed him to stop providing any emergency assistance he contacted the police department because "he did not die of natural causes." Paramedic 1 stated he remained at the facility until the police department arrived and advised the police officer of the food found in Patient A's mouth.

Review of the Prehospital Care Report completed by Paramedic 1, dated 02/17/07, documented the emergency call was received at 8:01 a.m., the unit was en route to the facility at 8:03 a.m. and was at the facility at 8:08 a.m. The report documented the paramedics were providing emergency care to Patient A at 8:10 a.m. and the care was stopped at 8:13 a.m. after being given the DNR from the facility.

An interview was conducted with Patient A's physician on 07/24/07 at 11:35 a.m. Patient A's physician stated the facility had contacted him regarding Patient A's death but was not aware of Patient A choking prior to his death. Patient A's physician was unaware of the coroner's report documenting the cause of death was due to a food bolus. Patient A's physician stated he would have expected the facility's nurses to provide emergency care to Patient A. Patient A's physician stated there was an order for oxygen to be given to Patient A if he was having problems breathing and the nurses should have "at least" provided him with additional oxygen. Patient A's physician stated he was disappointed with finding out Patient A had not died of "natural causes" and that staff at the facility had not provided him with even basic emergency care.

Review of Patient A's Coroner's Autopsy Report, dated 03/13/07, was completed on 05/10/07. The report documents a "Food Item" being received with Patient A's body. The food item "appears to be a peach half" in a plastic container. There were no teeth marks or bite marks on the portion of peach. The examination of Patient A's "Upper Digestive System" documented Patient A's oral cavity was free of food bolus or other material or objects. There was the presence of a "small yellow-orange soft chunk of what appears to be a small piece of peach" found in the oropharynx near the opening to the larynx. The cause of death documented on the autopsy was: "Asphyxiation (minutes) Due To: Obstruction of the airway by a food bolus [peach half] (minutes)".

The 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care note that death from a foreign-body airway obstruction is an "Uncommon but preventable cause of death". Rescuers were instructed to intervene if the choking victim had signs of severe airway obstruction which included poor air exchange and increased breathing difficulty. Interventions included quick action to relieve the obstruction, such as the Heimlich Maneuver.

Review of the facility policy and procedure titled "Choking-Heimlich Maneuver", undated, documented the Heimlich Maneuver was to be performed on patients whose airway was obstructed by a foreign object. The Heimlich Maneuver was to be performed by staff trained in the procedure. The Heimlich Maneuver was to be continued until the foreign body was expelled or the patient became unconscious. If the patient became unconscious the patient was to be placed on his back supporting the head and neck. CPR was to be activated. Staff was to check for a foreign body, perform a tongue-jaw lift and sweep deeply into the mouth along the cheek with a hooked finger to remove any foreign body, open the airway and give rescue breaths. If the airway remained obstructed abdominal midline thrusts were to be performed by pressing into the abdomen with quick upward thrusts 6-10 times to see if the airway would open. The sequence was to be repeated until emergency transfer was completed.

Patient A's date and time of death were 02/17/07 at 8:05 a.m. Initial staff recognized the possibility that Patient A was choking. As Patient A's care was passed on from one licensed staff member to another, the later staff failed to recognize and did not respond in the standard manner to clear Patient A's airway. A physician's order for "Do Not Resuscitate" (DNR) does not mean that a facility should not attempt a Heimlich Maneuver in order to prevent a choking death (unnatural cause of death). These failures resulted in Patient A's death.

The Department determined the facility failed to: 1. Identify Patient A's care needs while he was choking. 2. Provide emergency care and services to Patient A after he choked. 3. Implement and follow the facility policy and procedure for "Choking-Heimlich Maneuver", (undated).

These violations presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and were a direct proximate cause of death of the patient.