Asian Community Nursing Home
7801 Rush River Drive, Sacramento, CA 95831
Citation Number: 030009946
Citation Date: 6/4/2009
Violation Date: 1/5/2007
Class: AA
Penalty: $80,000


Nursing Service - Patient Care (g) Each patient requiring help in eating shall be provided with assistance when served, and shall be provided with training or adaptive equipment in accordance with identified needs, based upon patient assessment, to encourage independence in eating.

The following citation was written as a result of an unannounced visit, made on 3/19/12, to initiate an investigation of Complaint #CA00302503 concerning a patient who choked on a piece of meat while on a facility outing and subsequently died. The report identified allegations the facility failed to protect the patient from the risk of eating food of a texture she could not safely consume due to her difficulty with swallowing.

The Department determined the facility failed to: Provide meal assistance to Patient A, including cutting her meat into smaller pieces during a facility sponsored outing, to ensure Patient A ate foods in a form she could safely swallow.

This failure resulted in Patient A consuming a large piece of meat which blocked her airway and resulted in her death.

Patient A was an 86 year old female, originally admitted to the facility on 2/8/08 with diagnoses which included dementia with behavior disturbances, diabetes, and stroke.

Review of the clinical record for Patient A revealed a "Mental Status Examination" dated

5/5/09 which indicated a score of 25. The "Scoring" section was highlighted on the score range for patients who have a high school education, a score of "27-30 Normal; 20-27 MCI [mild cognitive impairment], 1-19 Dementia."

Review of a physician progress note, dated 5/13/09, under the heading "Dementia" indicated, "Although [Patient A] scored a 25 on the MSE [mental status examination] but she dramatically documented she could not comprehend directions and has abnormal spatial orientation, I believe the patient is able to compensate to a certain point. However with this recent examination of the clock drawing, this demonstrates the patient is unable to make sound decisions on her own."

Further review of the clinical record indicated the following physician's orders:

10/31/11, "May go on LOA [leave of absence]/outings for therapeutic reasons with the responsible party and/or staff, special instructions: and/or designee or recreational therapy assistants;"

6/4/11, "[Patient] has no mental capacity to make health decisions;"

6/4/11, "May deviate from therapeutic diet for planned activities;"

6/4/11, "May participate in activities not in conflict with treatment plan;"

6/6/11 , "Mechanical soft, NAS [no added salt], NCS [no concentrated sugar] diet."

A "Dysphagia Evaluation" (dysphagia means trouble swallowing) dated 6/7/11, reflected Patient A had moderate impairment with the oral phase of swallowing. The recommendations were for intermittent meal supervision, with a diet of soft chopped solids.

A care plan for mechanically altered diet, dated 6/13/11, included the following interventions: "Encourage to eat slowly and chew food ... observe for chewing problems."

A Progress Note, dated 1/9/12 at 12:28 p.m., reflected "Received phone call from activities director in regards to a change in condition .... patient noted to be choking and then became unconscious ... Spoke with paramedic via telephone with orders to send resident to [hospital name] for further evaluation. "

In an interview with Certified Nursing Assistant 1 (CNA 1] on 3/15/13 at 2:25 p.m. CNA 1 verified that she was on the facility's activity department outing to a market on 1/9/12, along with 2 other staff members and 1 volunteer. CNA 1 confirmed 5 residents were in the van and (Family Member 2 -FM 2] met the group and took (Patient A] shopping. CNA 1 confirmed the group had started eating when Patient A and FM 2 arrived at the table. CNA 1 stated she saw that Patient A "had noodles and meat."

In another interview with CNA 1 on 4/19/12 at 3:28p.m. CNA 1 stated she opened Patient A's food container to look at it, " ... For sharing, we're friends." CNA 1 denied she was looking at Patient A's food as part of her responsibilities as a facility employee.

In an interview with Activities Director 1 [AD 1] on 4/20/12 at 8:50a.m. she stated, "We were already sitting ... [FM 2 and Patient A] came with some food, when I saw the food I said (Patient A] you can't eat that...she was adamant about what she wants to eat. .. that wasn't her diet, mechanical soft, I said, 'Is that what you should have?' and she put her head down ... [FM 2] told her to slow down, he moved her food away ... [Patient A] was an alert resident, she knew her diet, she still insisted on that food ... everyone knows that about her ... When [FM 2] came back he said 'she's choking' I swept her mouth ... just noodles came out... I did the Heimlich, nothing but noodles came out. .. [FM 2] called 911 and I called the facility." AD 1 stated she had seen meat in the patient's food and stated, "It was so much food."

Review of a staff education sign-in sheet, dated 5/25/11, titled, "Choking Prevention," revealed both CNA 1 and AD 1 had attended the training. The class materials included, "Choking prevention. What can be done to prevent the injury? In many cases, choking can be prevented by: cutting food into small pieces and chewing slowly ... "

Review of the General Acute Care Hospital (GACH] clinical record included: A "Prehospital Care Report Summary" from the fire department crew, dated 1/9/12. The report documented the fire department arrived at 11:14 a.m. and found Patient A in "Cardiac arrest [without a heartbeat], airway (breathing] obstruction." The record included " ... complete airway obstruction, no pulse. CPR initiated. Suction brought up large chunks offood, intubation [insertion of a breathing tube] (no] success ... attempted intubation 2 [times without] success. Suction continued to remove chunks of food, CPR [cardiopulmonary resuscitation] maintained ... to ER [emergency room]."

Dictated physician notes, dated 1/9/12, titled, "Cardiopulmonary arrest" included, "Given history of choking, we attended to the airway primarily ... We were able to visualize a large piece of what appeared to be meat obstructing the airway when we looked with direct laryngoscopy [a tool used for visual examination of the airway]. This was removed with a [brand name] forceps and the patient was easily intubated [artificial airway] ... There was some food material/vomit coming from the endotracheal tube [artificial airway] and this was suctioned."

An "Admission/Discharge Information" form, dated 1/10/12, included, "Disposition Died-expired 1/10/12 ... Principal Diagnoses: 1. Asphyxiation due to choking on meat; 2. Acute respiratory failure ... 6. Coma due to anoxic encephalopathy ... " The report included, " ... 20 minutes had elapsed between her collapse and her arrival in the ER. The ER physician was able to remove the giant piece of meat sitting on top of the patient's glottis with forceps ... "

Review of the "Certificate of Death" for Patient A identified the, "Cause of Death Asphyxiation due to choking on food."

During an interview with MD 1 on 4/24/12 at 10:47 a.m. MD 1 stated that when she wrote an order allowing Patient A to deviate from her therapeutic diet for activities, her goal was for the patient to have, "Foods to her liking, to get her more interested in food, but also with precautions."

During an interview with Speech-Language Pathologist 1 [SLP 1] on 4/27/12 at 8:30 a.m. SLP 1 reviewed the Dysphagia Evaluation, dated 6/7/11, and stated the patient "had challenges with chewing chopped meat..." When asked if facility staff needed to cut Patient A's food, SLP 1 stated, "Yes."

During an interview with Registered Dietician 1 [RD 1] on 4/27/12 at 9:05a.m. RD 1 stated the facility's mechanical soft diets included, "chopped meat." RD 1 reviewed the picture of Patient A's food from the market, which had been taken by facility staff during the outing, and stated, "This picture is not chopped [meat]."

In an interview with the Administrator and the Director of Nurses on 1/17/13 at 12:35 p.m. they stated staff meal supervision involved a, "Staff member eyeballing the [patient] to make sure they don't need help."

The facility failed to provide meal assistance to Patient A, including cutting her meat into smaller pieces during a faci lity sponsored outing to ensure Patient A ate foods in a form she could safely swallow. This failure resulted in Patient A consuming a large piece of meat which blocked her airway and resulted in her death.

These violations presented either (1) imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom, or (2) substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result therefrom and were a direct proximate cause of the death of the patient or resident.