Emeritus at Yorba Linda
17803 Imperial Highway, Yorba Linda, Ca 92886
Citation Number: 060008760
Citation Date: 08/09/2011
Violation Date: 1/30/2011
Class: AA
Penalty: $ 90,000

The following reflects the findings of the Department of Public Health during a Complaint Investigation visit:

Complaint(s): CA00270705

Representing the Department of Public Health: Surveyor ID # 25719, HFEN '

The inspection was limited to the specific facility event investigated and does not represent the findings of a full inspection of the facility.

(a) Nursing service 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.
(2) Implementing of each patient's care plan according to the methods indicated. Each patient's care plan shall be based on this plan.

Therapeutic diets shall be provided for each patient as prescribed and shall be planned, prepared and served with supervision and/or consultation from the dietician. Persons responsible for therapeutic diets shall have sufficient knowledge of food values to make appropriate substitutions when necessary.

The licensee shall .. maintain.. written .. transfer agreements with other nearby health facilities to make the services of those facilities accessible and to facilitate the transfer of patients. Complete and accurate patient information, in sufficient detail to provide for continuity of care shall be transferred with the patient at time of transfer.

The facility failed to provide finely chopped meat for Patient A, as ordered by her physician.

The facility failed to provide Patient A with her dentures when her lunch was served.

The facility failed to implement their plan of care by not providing supervision when Patient A was eating lunch. Patient A was found unattended, unresponsive and cyanotic (blue color from lack of oxygen), with a partially eaten sandwich in front of her. The Heimlich maneuver (an emergency technique used. to prevent suffocation when a person is choking) was performed and was unsuccessful. Patient A was transferred to the acute hospital, where a large piece of meat was removed from her airway. Patient A was admitted to the intensive care unit, where she remained unconscious and died six days later from cardiac and respiratory arrest due to foreign body aspiration (choking). Findings:

Review of the facility's P&P (policy and procedure) titled "Therapeutic Diets" undated, showed the facility should provide each patient with a therapeutic diet as ordered by the physician to ensure e.ach patient receives the correct prescribed diet.

On 5/31/11 , closed health record teview for Patient A was initiated. Patient A had a history of a stroke and difficulty chewing and swallowing. ·The Minimum Data Set (an assessment tool) dated 12/1/10, showed Patient A had impaired cognition and required moderate assistance from staff for activities of daily living and supervision during meals.

A physician's order dated 3/8/10 , showed an order for a mechanical soft, finely chopped diet and to be up in the dining room for all meals.

The Interdisciplinary Progress Notes dated 12/9/10, showed Patient A required a mechanical soft diet with finely chopped meats due to "chewing problem."

A care plan problem titled "Dining" dated 12/6/10, showed Patient A required supervision for all meals. The facility's dietary spreadsheet menu dated , showed on an alternate lunch provided was a ham sandwich. The facility's recipe for ham sandwich showed for patients receiving mechanical soft diet, the meat is to be ground or chopped.

The Nurse's Notes dated 1240 hours, documented by RN (Registered Nurse) 1, showed CNA (Certified Nursing Assistant) 1 summoned LVN (licensed Vocational Nurse) 1 because Patient A did not "look good" and was "turning blue or purple." LVN 1 noticed the patient's lunch tray on her bedside table and immediately checked the patient's airway but the patienfs mouth was clenched shut. Patient A was "purple, cyanotic" and "nonresponsive" and oxygen was administered to the patient. The Heimlich maneuver was attempted by LVN 1 without success. LVN 1 then summoned RN 1.

The Nurse's Notes showed at 1241 hours, Patient A's family member was notified by telephone and at 1242 hours, 911 was called. At 1247 hours, the emergency response team arrived. LVN 1 told them Patient A was turning purple and the patient's lunch tray was in front of her when she was found. The Heimlich maneuver was attempted. At 1300 hours, Patient A was transferred to the acute hospital.

On 6/1/11 at 0745 hours, during an interview with LVN 1, the l VN stated CNA 1 called her for help and when she arrived to Patient A's room, the patient was in bed and looked blue. LVN 1 stated Patient A had eaten some of her sandwich and foam was coming out of the patient's mouth. LVN 1 stated the patient was unresponsive but had a pulse. l VN 1 stated CNA 1 told her the patient had been eating and maybe she was choking. The l VN stated the patient's jaw was clenched tightly and she could not perform a mouth check or sweep.

The LVN stated she attempted "back blows" and the patient was limp. The LVN stated RN 1 came to the room and she asked the RN to check the patient's code status and to call the patient's family member. The LVN stated Patient A had a seizure that morning and they kept . her in bed for lunch that day because she was usually weak after a seizure. LVN ,1 stated she documented the incident in an "initial report."

On 6/1/11 at 0830 hours, during an interview with DSS (Dietary Services Supervisor) 1, the DSS stated the ham used in a sandwich for a mechanical soft finely chopped diet would be prepared by chopping up the meat.

On 6/1/11 at 0915 hours, during an interview with CNA 1, the CNA stated she dropped off the lunch tray at Patient A's bedside and then left the room to pass out other patient's trays. CNA 1 stated when she returned to Patient A's room, she noticed the patient's color was grey and purple and she had foam coming out of her mouth. The CNA stated Patient A was sitting up in bed with her tray in front of her. She stated Patient A was served a ham sandwich and a bite had been taken out of the sandwich. The CNA stated the ham was in the form of a slice, not chopped. The CNA stated Patient A had some bottom teeth but no top teeth and she wore an upper denture. The CNA stated she "forgot" to place the upper denture in Patient A's mouth before the lunch meal was served that day. The CNA stated they all thought she was "choking" and the ham sandwich was an "issue."

On 6/1/11 at 1135 hours, during an interview with Patient A's family member, she stated on she received a telephone call from RN 1. The RN told her Patient A was turning blue and asked her permission to send the patient to the acute hospital and she agreed to the transfer. She stated she was not told Patient A was possibly choking. The family member, stated· she ~ent to the acute hospital's emergency room and spoke with the emergency room physician. However, she stated the emergency room physician talked to her about intubating (a flexible tube placed into the trachea to open and maintain an airway) Patient A to provide ventilation and to try and find out why the patient was in respiratory distress. The family member stated when the emergency room physician was attempting' to place the tube he pulled out a "wad of ham." She stated the emergency room physician told her it was a good decision to intubate because they now knew the cause of the respiratory distress. She ~tated Patient A was then admitted into the intensive care unit and never regained consciousness and died. The family member stated she had contacted the facility a day or two after the patient went to the hospital to express her concerns. The family member stated the DON (Director of Nursing) told her Patient A not having her dentures in at the time she ate lunch was a mishap.

On 6/1/11 at 1545 hours, during an interview with Physician 1, the physician stated he received a phone call from the facility telling him Patient A was in respiratory distress. Physician 1 stated the patient was transferred to the acute hospital and he spoke with the emergency room physician. Physician 1 stated the emergency room physician toid him slices of ham were removed from Patient A's airway. Physician 1 stated the patient was then transferred to the intensive care unit. On 6/22/11 at 1125 hours, during an interview with the DSS 2, the OSS stat~d the incident happened on the weekend and when she returned to work she heard Patient A had been sent to the hospital. The DSS stated she was unaware of the circumstances at the time but later found out Patient A had choked. The OSS stated the facility traced it back to a ham sandwich. The OSS stated they received a report from the acute hospital showing the p'atient had choked.

On 6/22/11 at 1510 hours, during an interview with the ST {Speech Therapist), the ST stated [f a patient was used to eating with dentures in, then she would expect the dentures to always be used when the patient was eating. The ST stated Patient A was encouraged to eat meals in the dining room because she would be sitting upright in a chair and staff would be supervising her.

On 6/24/11 at 0945 hours, ·during an interview with RN 1, the RN stated she was called to help LVN 1 in Patient A's room. RN 1 stated she was asked to check Patient A's health record for her "code status" {a set of instructions outlining treatment to be given in the event of an emergency) and to call the patient's family member and 911. RN 1 stated the paramedics arrived and transferred the patient to the acute hospital. RN 1 stated she documented the account of the incident, including the Heimlich maneuver, in Patient A's health record for LVN 1. The RN stated she was helping LVN 1 by documenting the note because VN 1 was "uneasy" and "distraught" about what happened. VVhen asked if she was part of any facility investigation, the. RN stated yes, she provided a written account the following day, When the RN was asked if the facility made any conclusions as a result from their investigation, the RN stated shortly after the incident they received a report showing the patient had choked.

Review of the ambulance service's Patient Care Report dated , showed an emergency call was received at 1242 hours. The chief complaint was "unresponsive" and Patient A was found in bed and unresponsive.

On 7/25/11 at 1605 hours, during an interview with EMT (Emergency Medical Technician) 1, the EMT stated he responded to an emergency call made at the facility. The EMT stated the call came in indicating a patient was in respiratory distress and he arrived just before the fire department. EMT 1 slated if he had known the patient was a possible choking victim, he would have noted that on his report. The EMT stated he later found out Patient A had a large chunk of meat deared from her throat at the hospital from hospital staff.

On 8/4/11 at 1020 hours, during an interview with Physician 2, the physician stated Patient A was brought into the emergency department in "extreme" respiratory distress. Physician 2 stated he removed a slice of ham from the patient's airway. He stated the ham was not chopped. Physician 2 stated the EMTs and the paramedics did not have any knowledge that Patient A may have been choking.

Review of the acute hospital's emergency room physician's report dated , showed .Patient A arrived in severe distress with severe labored breathing. The physician documented possible causes were "unknown .'' A piece of meat was then removed from the patient's throat.

The acute hospital's pulmonary consultation dated , showed Patient A had a "large piece of meat lodged in her airway" and had subsequent respiratory failure. The acute hospital's neurological consultation dated , showed Patient A "had aspirated piece of meat" and required intubation and placed on a ventilator (a machine which mechanically moves air into and out of the lungs). Patient A did not regain consciousness.

Review of the acute hospital's discharge summary dated showed Physician 1 documented Patient A had a foreign body aspiration, which led to hypoxia (lack of oxygen) and respiratory failure. Physician 1 documented Patient A aspirated a "big chunk of ham." A computed tomography scan was negative for any acute neurological events. The patient's cause of death was cardiopulmonary arrest due to hypoxemia and respiratory failure.

Review of the Certificate of Death showed Patient A's cause of death was cardiopulmonary arrest due to respiratory faiiure due to foreign body aspiration.

Review of the Coroner's report dated 2/9/11, showed Patient A's cause of death was cardiopulmonary and respiratory arrest due to foreign body aspiration. The manner of death wa~ an accident.

Review of the Orange County Sheriff Coroner's Case Notes report dated 4/26/11, showed Patient A's death was reported to them by the acute hospital. The report showed the patient's family member stated there ·were times when the patient's food was not cut up and she was found unsupervised while eating. The family member spoke with the emergency room physician and was told he pulled a nearly intact slice of ham from the patient's throat which was blocking her airway. The family member found out from the facility that Patient A was not feeling well that day and stayed in bed. A whole ham sandwich was served to the patient, she was unsupervised and she did not have her dentures ln place. The report showed Physician 1 spoke to the emergency room physician and was told a chunk of sliced ham was removed from the patient's airway. The incident happened on while the patient was unsupervised and "per the doctor, that food sho~ld have never been on that plate."

The facility failed to provide Patient A with her dentures, supervision and finely chopped meat as ordered, causing Patient A to choke to death.

These violations, jointly, separately or in any combination, 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 were a direct proximate cause of death of the patient.