Golden Living Center - San Jose
401 Ridge Vista Avenue, San Jose, CA 95127
Citation Number: 070008230
Citation Date: 5/16/2011
Violation Date: 4/24/2011
Class: AA
Penalty: $ 80,000


F323 -483.25(h) Free of Accident Hazards/Supervision/Devices

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 provide supervision and assistance to prevent choking hazard to one of 22 sampled residents (22). Resident 22 was not supervised by staff on 4/24/11 during the Easter social party as required in her assessment and care plan. Resident 22 was found unresponsive and was transferred to the acute care hospital where she expired on 4/26/11. Findings:

Resident 22 was admitted to the facility with diagnoses including schizoaffective disorder (mental illness) and Alzheimer's disease. The 3/10/11 Minimum Data Set, an assessment tool, indicated Resident 22 was moderately impaired in cognition, and required extensive assistance with one person physical assistance during dining. Resident 22 was conserved by the local public guardian.

The social progress note dated 12/9/10 indicated: "Resident is on consistent carbohydrate puree diet with a usual intake of 100% during meals. Resident has to be fed by the staff to avoid aspiration. Resident is eating fast and not really chewing her food before swallowing. Resident is edentulous (without teeth) and has dentures".

The 1/11/11 dentist's evaluation indicated Resident 22 "does not wear denture; eating well without denture".

On 1/24/11, the attending physician ordered a pureed CON [consistent] CHO [carbohydrate] small diet for all three meals based on the recommendation of the facility registered dietitian. Puree is cooked food that has been ground, pressed, or blended to the consistency of a soft creamy paste or thick liquid. Physician orders dated 12/2/08 and renewed on 712110, under Ancillary state: "May have no diet restrictions on special occasions".

A care plan dated 1/20/11 indicated Resident 22 required staff assistance with feeding to maintain her safety. "Resident tends to rush through meals, eats too fast and swallows without chewing food posing a choking hazard". Care plan interventions included "eating assistance as needed".

The facility corporate registered dietitian (RD 1) wrote a care plan dated 3/31/11 which indicated Resident 22 "eats food very quickly, does well with blenderized puree; weight gain since admission". "Blenderized puree" meant using a blender to alter the consistency of the cooked food to a creamy paste or thick liquid. Care plan interventions included "provide supervision and redirection meal service and snack times". The facility did not care plan how Resident 22 would be supervised on special occasions when diet restrictions were off.

A progress note dated 3/21/11 written by a program counselor indicated "encouraged her to swallow food slowly to avoid choking hazard".

The dietary services manager (DSM) wrote a note dated 4/14/11 "staff continues to monitor at mealtime as resident tends to get extra food with every opportunity; current weight is 178.6 pounds; weight changes not significant but is not desired for the resident".

The facility consultant registered dietitian (RD 2) note dated 4/20/11 indicated "adjust diet to consistent carbohydrate puree".

Resident 22 had the 4/24/11 noon meal consisting of beef, sauteed onions, au gratin potato, green beans, bread slice and white cake, which were all pureed.

A progress note indicated vital signs of Resident 22 taken before 9:00 a.m. on 4/24/11 were: blood pressure = 129/61, respiratory rate = 20, and heart rate = 76.

Licensed nurse A (LN A) wrote a note dated 4/24/11 at 2:20 p.m.:

Resident 22 was "having Easter party at the middle room adjacent to V room with other residents. Per CNA [certified nurse assistant] who noticed resident change of condition, resident was observed to be silent and unresponsive with bluish discoloration of the lips".

During an interview on 5/2/11 at 2:45 p.m. LN A stated he was at the chart room on 4/24/11 at 2:20 p.m. when certified nurse assistant C (CNA C) called him for an emergency. LN A rushed to Resident 22's room, and saw the resident sitting on the wheelchair, unconscious and unresponsive to verbal and tactile (by touch) stimulation with bluish discoloration of the lips and a non-palpable (not felt) pulse.

LN A immediately performed cardiopulmonary resuscitation (CPR) and instructed other staff to call 911. LN A stated he noticed salivary secretions drooling from Resident 22's mouth. LN A opened the resident's mouth with one hand and continued chest compression with his other hand. LN A inserted two ingers in the resident's mouth and extracted a "piece of previously taken food". LN A stated it looked like the cupcakes served during the Easter social party.

LN A stated that at this point in time (4/24/11 at 2:35 p.m.) he was unable to get vital sign readings. LN A stated it was at this time the 911 paramedics arrived and took over the chest compressions. LN A stated Resident 22 was sent to the acute care hospital at about 2:55 p.m. on 4/24/11.

During an interview on 5/3/11 at 8:00 a.m. certified nurse assistant B (CNA B) stated she was assigned to Resident 22 for the day shift on 4/24/11. CNA B stated Resident 22 requested that she take her to the middle classroom so she could attend the Easter social party. CNA B stated cupcakes with different colored icings on top, juice and water were being served at the party. CNA B stated she left the middle classroom as soon as she brought Resident 22, to attend to her other residents. CNA B stated she did not see how Resident 22 acquired the cupcakes. No staff was supervising the resident directty.

CNA B stated she was providing care to other residents when CNA C took Resident 22 in her wheelchair back to the resident's room. CNA C shouted to CNA B "code blue" signifying an emergency situation. Both CNAs went to Resident 22's room.

CNA B stated she, CNA C, LN A, and program counselor staff were in the room. CNA B stated she could not get readings when she felt the resident's carotid (neck) pulse and attached the blood pressure equipment. CNA B stated she saw LN A doing chest compressions. CNA B stated CNA C extracted "lots of pieces" of chocolate brown cupcake similar to the ones served in the Easter social party.

During an interview on 5/3/11 at 8:25 a.m. the program counselor (PC) stated. that program counselor staff were distributing cupcakes, the only solid food served in the party. The PC stated the cupcakes came in different colors but she remembered the chocolate brown color. The PC stated she saw Resident 22 during the party. The PC stated she did not know how Resident 22 got the cupcake. The PC stated she became aware there was a problem when she saw CNA C move Resident 22 from the middle classroom.

During an inteview on 5/3/11 at 8:50 a.m. the DSM stated the activity director requested cupcakes to be supplied to residents during the Easter social party. The DSM stated she ordered the supply of cupcakes from the facility food vendor.

The DSM stated the cupcakes were the only solid food items served at the Easter social party and they were given out to the residents present at the party as received from the food vendor. The DSM stated the cupcakes were not appropriate for Resident 22 to eat because the resident was on a puree texture diet. The DSM stated the cupcakes would have to be pureed using the standard procedure the kitchen staff used with the pureed white cake served during the 4/24/11 noon meal to prevent a choking hazard for Resident.

During an interview on 5/4/11 at 7: 15 a.m. CNA C stated as a high-risk CNA she was responsible for conducting a resident head count to ensure no residents eloped from the facility. CNA C stated when she arrived to the middle classroom on 4/24/11 at 2:20 p.m. she found Resident 22 sitting in her wheelchair and looking pale. CNA C tried to rouse Resident 22 but the resident was unresponsive.

When asked why she did not intervene to correct a potential choking episode, CNA C stated she did not think Resident 22 choked because the resident was unresponsive and pale and did not have cupcake-looking food in her hands. CNA C stated she helped LN A extract three pieces of dark chocolate colored substance from Resident 22's mouth which looked like cupcake.

Review of the acute care hospital emergency department of the acute care hospital physician assessment dated 4/24/11 at 6:00 p.m. indicated:

The facility staff reported to the 911 paramedics Resident 22 "was last seen alive on 4/24/11 at 2:10p.m., and she was seen eating a cupcake. Nurses state that the patient was found lying on the bed, pulseless and apneic (without breathing) with vomit on the bed. The patient was initially in asystole (no pulse). Patient was administered 1 milligram of epinephrine and 1 mg of atropine intravenous push with return of pulses. The patient then went from a sinus tachycardia (rapid pulse) to a ventricular tachycardia, was pulseless again. The patient was administered 100 milligrams of lidocaine intravenous push with the patient then going into normal sinus rhythm at a rate of 90. The patient was placed onto the gurney and transported to the ambulance. During the transport, just prior to the arrival to the emergency room, the patient went into pulseless electrical activity. CPR was initiated and the patient was administered 1 milligram of epinephrine intravenous push with pulses returned and no other changes during transport."

Resident 22 was transferred to the intensive care unit (ICU) on 4/24/11 at 6:00 p.m. The discharge summary dated 4/26/11 indicated:

"Throughout the resident's intensive care unit stay she persistently would demonstrate neurologic instability manifesting itself as a comatose state void of any significance sedatives to cause such a neurologically distributive shock and neurologic fevers with periodic myoclonus and seizure activity. The resident was assessed by neurology and critical care services, and early on the prognosis was predicted to be poor. This was conveyed to the conservator's office, and the conse vator directed the medical team to seek two medical opinions. After a second medical opinion from neurology was rendered as to the extremely poor prognosis for this resident and both parties recommended comfort care, comfort care was indeed applied and a do not resuscitate was placed on the chart. The resident ultimately continued to progress to pass from the natural progression of her stroke disease and ceased vital signs including respirations and pulse on April 26, 2011 at 1731".

The discharge summary dated 4/26/11 indicated cause of death was global anoxic brain injury (days) secondary to food aspiration/asphyxiation (accidental) in the setting of Alzheimer's dementia, hypertension, hypothyroidism.

Therefore, the facility failed to provide supervision to prevent a choking hazard to Resident 22 on 4/24/11 during the Easter social party. The resident became pulseless and/or comatose after the 911 paramedic and later the acute care hospital staff performed procedures to restore her pulse.

This violation 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 was a direct proximate cause of the death of the resident.