Homewood Care Center
75 N. 13th Street, San Jose, CA 95112
Citation Number: 070006742
Citation Date: 03/11/2010
Violation Date: 8/24/2009
Class: AA
Penalty: $ 80,000

F224 483.13(c) Staff Treatment of Residents

The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse o.f residents and misappropriation of resident property .

The facility failed to provide the necessary services to prevent harm when staff failed to promptly respond to a life-threatening situation involving one of three sampled residents (1 ).

The facility failed to perform an emergency procedure (Heimlich maneuver) to assist Resident 1 in clearing his obstructed airway on 8/24/09.

Resident1 was assessed as a high risk for aspiration due to difficulty in swallowing. On 8/24/09 at 5:20 p.m., certified nurses assistant A (CNA A) was feeding the resident his dinner when suddenly Resident 1 started coughing. Accordihg to documentation gathered, Resident 1 was gasping for air and became distressed. Although staff suspected Resident 1 was choking on food, no. immediate attempt was made to. perform abdominal thrusts to clear the resident's obstructed airWay.

The facility failed to promptly call 911 for emergency services. The facility staff stated . they called 911 (paramedics) at 5:30 p.m. However, according to the emergency dispatch office, the facility called at 5:49 p.m.; a delay of approximatelyt9 minutes. An investigative report from the police indicated the resident was already deceased when the paramedics arrived on the scene. Resident 1 was pronounced dead at 6:09 p.m. on 8/24/09.

Resident 1's medical record indicated that he was admitted to the facility with diagnoses including Alzheimer's disease and dysphagia (difficulty swallowing). The Minimum Data Set (MDS), an assessment tool, dated 7/28/09 indicated Resident 1 had short and long-term memory loss, was severely impaired, and was totally dependent on staff for eating. Resident 1 was on aspiration precaution (use of special feeding techniques to assist with swallowing) and had a physician's order dated 7/17/09 for a puree diet with honey thick liquids.

The Preferred Intensity Level of Treatment form dated 7/17/09 indicated when necessary the resident's preference was to be transferred to an acute care hospital. The form also indicated a "No CPR" (cardio-pulmonary resuscitation). The form specified "No CPR" meant no cardiac compression, defibrillation (stimulate heart electrically), intubation (insert tube into windpipe to provide oxygen), mechanical ventilation, ACLS (advanced cardiac life support) medications or vasopressors (medications to raise blood pressure). Nevertheless, the definition of "No CPR" did not preclude the performance of abdominal thrusts as done during a Heimlich maneuver.

During an interview on 11/16/09 at 4:02 p.m., CNA A stated around 5:20 p.m., she was feeding Resident 1 while he was in his bed and sitting with his head up about 50 degrees. After she fed the resident two spoonfuls of pureed food, Resident 1 started coughing. CNA A stated she immediately called for registered nurse B (RN B) to come to the resident's room. CNA A stated RN B came but then left the room. CNA A also stated she did not attempt to ask Resident 1 to spit up anything because when she opened the resident's mouth, she stated there was "no food" and so she did not "push on his stomach".

During an interview on 11/16/09 at 4:30 p.m., licensed nurse F (LN F) stated the resident was non-responsive when he entered the room. He was unable to state the exact time he entered the room but stated Resident 1 was having shallow and labored respirations. LN F stated the resident's oxygen saturation was only 54% (therapeutic range is 94% to 100%) so he grabbed an oxygen tank to administer oxygen.

During review on 11/16/09, the licensed nurse's progress note dated 8/24/09 at 5:35 p.m. indicated "resident was not looks good, assess resident right away, found resident in bed, face looks pale, no verbally responsive." It further indicated Resident 1 "can not open his eyes (resident usually can be verbally responsive)." The note indicated when touched, Resident 1 moved his face but his breathing was slow and shallow and when the resident's mouth was opened there was no food found. With no timeline documented, the note further indicated, "Inform to MD office & (and) try to call the son (name), but he did not answer telephone. So, left message, resident is no CPR but hospitalization @ (at) this time."

The resident's vital signs (normal ranges accessed at http://www.healthsystem.virginia.edu/uvahealth/adult_nontraumalvital.cfm) were recorded as follows: blood pressure of 60/40 (normal reading is in the range of 120/80), pulse 32 (normal range is 60 to 100 beats per minute), respirations 8 (normal range is 15 to 20 per minute) and the temperature was 96.4 degrees Fahrenheit (F) (normal is around 98.6 degrees F). The note had no time documented when the resident had, "02 sat (oxygen saturation) 60% RA (room air). So, call 911, about 3-4 min (minutes), 911 team came ... " The note indicated the licensed nurse called 911 only after ,she had made attempts to call the physician and the resident's son.

During an interview with RN Bon 11/16/09 at 3:30 p.m., she stated she was not sure of the exact time CNA A called her to go to Resident 1 's room. When she arrived in the room, she stated the resident was lying in bed, with the head of his bed at a 50-degree angle. RN B stated Resident 1 was "pale, breathing really slow, moving his head and was not verbally responsive." She said she suspected Resident 1 choked on the food. She said she also could not remember what kind of pureed foods were served to the resident. RN B stated she left the room to call the paramedics.

During review on 11/16/09, there was no documented evidence in Resident 1 's medical record that staff attempted to clear the resident's obstructed airway as done in a Heimlich maneuver.

During review on the same date of the skilled nursing facility's (SNF) records, it indicated a staff in-service about an "Obstructed Airway: Conscious Adult" was conducted on 6/29109. The in-service included instructions for when a person is choking, to use abdominal thrust and repeat the thrust until the obstruction is cleared.

During review on 11/16/09, the police officer's (investigative) report dated 10/5/09 regarding the death of Resident 1 indicated the emergency fire personnel summoned the police to the facility on 8/24/09.

The police officer's report indicated the emergency dispatch office verified the facility called them at 5:49 p.m. The paramedics were dispatched immediately. When the paramedics arrived, the resident was already deceased and they pronounced him dead at 6:09 p.m.

The police officer's report indicated on 8/24/09 around 5:20 p.m., CNA A was feeding the resident puree diet with a spoon. CNA A stated the resident was not swallowing the pureed food and was only "moving his face". Then Resident 1 started gasping for air and his eyes were moving in distress. CNA A ran and got RN B for help.

The police officer wrote that CNA A stated she fed Resident 1 two spoonfuls of food starting at 5:20 p.m. When the resident started choking, RN B immediately responded and after they attempted resuscitation, called the emergency medical services (EMS-911) at 5:30 p.m.

The same report indicated when the police officer asked staff how they intervened with the choking, they stated they "propped the resident up in bed and patted him on the back." The police officer's report indicated at no time did any of the nurses describe doing a Heimlich maneuver (an emergency procedure using abdominal thrusts to clear the airway of a choking victim).

A further review on the same date of the SNF's in-service teaching plan for "Obstructed Airway: Conscious Adult" conducted on 6/29/09 indicated if there is a suspicion the person is choking, "Do not pat the person who is choking on the back. When you do, you risk jarring the object and having it settle more firmly, completly (sic.) cutting off the airway."

The police officer's report reviewed on 11/16/09 also indicated the police officer noted a discrepancy when the emergency call from the facility came 20 minutes later than the staff claimed. Although the facility staff stated they called the emergency services at 5:30 p.m., the emergency dispatch office noted the call was received at 5:49 p.m.

The police officer's report indicated Resident 1 was already deceased before the emergency services (paramedics) arrived in the facility. It documented Resident 1 was in "asystole, pulseless and apnetic {sic}." The police officer wrote the nurses claimed they called the paramedics immediately when the resident st~rted choking. The same report indicated the facility's nurses maintained they had suctioned and given the resident oxygen. The report indicated the Fire personnel found the suction machine sitting on a nightstand, clean, with no tubes attached, and it was not plugged in. According to the same report, the oxygen was not running (not administered) at the time the paramedics arrived at the facility.

The medical examiner investigator's report was reviewed on the same date and it indicated the nursing staff told the fire personnel "they used an oxygen machine". However, the "(name) fire personnel found the machine in the hallway, still with a plastic cover on it". During review on 11/16/09, the coroner's autopsy report for Resident 1 dated 10/27/09 documented "the cut surface of the larynx and adjacent trachea indicated a dark red mucosa approximately 30 ml of beige finely particular fluid ." The coroner's report further indicated that multiple sections of the lungs showed the presence of food matter in the small airways. The pathological diagnosis included aspiration of food bolus, asphyxia (lack of oxygen), and abundant particular fluid present within the upper and lower airways. The coroner determined the resident's cause of death was asphyxia due to aspiration of food bolus.

Although Resident 1 had requested not to be resuscitated if his heart stopped, Resident 1's heart had not stopped when he coughed while being fed. According to the online article entitled "Part 4: Adult Basic Life Support" by American Heart Association and accessed at (http://circ.ahajournals.org/cgi/reprinU112/24_suppl/IV-19), regarding "Foreign-Body Airway Obstruction (Choking)", pages IV-28 and IV-29, staff must act quickly if the foreign body airway obstruction (FBAO) produces signs of severe airway obstruction. Severe airway obstruction can occur when the cough becomes silent and respiratory difficulty increases or the victim becomes unresponsive. The EMS system should be activated quickly if the resident is having difficulty breathing. Also, if more than one rescuer is present, one rescuer should attend to the choking victim while the other person telephones 911.

In case reports involving severe FBAO, the article states there is increased success when performing the combined techniques of back blows or "slaps", abdominal thrusts and chest thrusts. The article also indicates that in a series of choking episodes report, 50% of airway obstructions were not relieved by performing a single technique. Although the same article indicated " ... chest thrusts, back slaps and abdominal thrusts are feasible and effective for relieving severe FBAO in conscious (responsive) adults ... " in order to simplify training the recommendation is for "the abdominal thrust be applied in rapid sequence until the obstruction is relieved". Given that abdominal thrust is an emergency technique performed to clear an obstructed airway prior to CPR, the same article states, "If the adult victim with FBAO becomes unresponsive, the rescuer should carefully support the patient to the ground, immediately activate EMS, and then begin CPR."

The facility failed to provide the necessary services and promptly intervene to clear Resident 1's airway when he started choking. Although the resident was distressed and gasping for air, the facility staff did not attempt to perform abdominal thrusts, (a standard of practice when choking occurs) to clear Resident 1's obstructed airway. Even though the facility's in-service for an obstructed airway instructed for staff to use and repeat abdominal thrusts until the obstruction is cleared, none of the staff members present made any attempt and were not aware of the other effective techniques to clear the resident's obstructed airway.

The facility failed to ensure prompt medical treatment and services when they were slow in activating the emergency medical services (call 911). Consequently, Resident 1's condition declined and he was already deceased when the emergency medical personnel arrived at the scene.

Therefore, the staffs' violation of their own FBOA policy and their failure to act and perform the Heimlich maneuver on Resident 1 presented the imminent danger that death or serious harm would result. The staffs' failure to perform the Heimlich maneuver was the proximate cause of the death of Resident 1.