Villa Rancho Bernardo Care Center
15720 Bernardo Center Drive San Diego, CA 92127
Citation Number: 080009783
Citation Date: 03/13/2013
Violation Date: 10/28/12
Class: AA
Penalty: $100,000

CLASS AA CITATION-- DIETARY

F365 (CFR 383.35(d)
Food prepared in a form designed to meet individual needs.

The facility failed to follow the physician's orders for a chopped diet. The Cook, the Dietary Line Checker, the Licensed Nurse and the Certified Nursing Assistant did not verify that the prescribed diet, in the correct consistency, was checked prior to bringing the meal tray into Resident 1's room. Resident 1 was known to have behaviors, in which he immediately grabbed for food and stuffed the food into his mouth. As a result, Resident 1 grabbed 2 pancakes and 2 uncut whole sausage patties from his breakfast tray and put all 4 items into his mouth. The resident choked on the food and died.

Resident 1, a 61 year old male resident, was admitted to the facility on 9/26/12 with a diagnosis of dementia (memory loss) per the Record of Admission. According to the Physician's Orders dated 9/26/12, Resident 1 had cognitive/behavior impairment (decreased mental status).

Resident 1's clinical record was reviewed on 10/31/12. The resident was unable to make medical decisions for himself per the Advanced Healthcare Directive, signed and dated by the physician on 9/28/12. According to the Minimum Data Set (MDS) assessment, dated 10/3/12, the facility assessed Resident 1 with unclear speech, unable to understand others or be understood by staff, and unable to make daily decisions due to severe cognitive impairment. Per the same document, the facility assessed Resident 1 as requiring limited assistance with feeding himself and the assistance of one staff member for supervision. According to the Social Service assessment dated 9/26/12, Resident 1, "Speaks with few words: yes, no, eat, hungry...Can become aggressive especially when eating."

Resident 1 was prescribed a mechanical soft, chopped diet, according to the DISTRICT OFFICE Physician's Orders dated 9/26/12. The Physician's Orders were updated on 10/5/12 to include, "Feeding 1:1 (one staff to one resident) w/ (with) all meals re: at choking risk." An Interdisciplinary Team (IDT) review was completed on 10/5/12. According to the IDT notes, staff were instructed to watch the food trays and the food cart, as Resident 1 was, "Always looking for more food," and needed to be redirected frequently. The resident was placed on 1:1 (one staff member to one resident) during meals due to his behaviors.

On 10/30/12 at 1 P.M., the Cook was interviewed by phone. The Cook said he worked the breakfast meal on 10/28/12. He said it was his responsibility to match the ticket (diet order) and plate the food on the kitchen line. The cook said he prepared a chopped diet of sausage and pancakes for Resident 1. He said he would usually chop the sausage patty into 9 pieces. The pancakes were not cut, as they were soft.

The Food Line Checker, a second person that reviewed the diet for correctness, 10/30/12 at 1:15 P.M., she was quite busy on 10/28/12. She said since it was a Sunday, she was responsible for answering the phone and responding to requested food changes. She said she was also responsible for checking the trays before the trays were loaded onto the service cart and taken to the nursing station. The Food Checker said the phone rang frequently on 10/28/12. She was uncertain if she reviewed all of the trays on the line that morning.

Licensed Nurse (LN) 1 said on 10/31/12 at 1:30 P.M., she was the Charge Nurse on the day shift on 10/28/12. She said she was aware that Resident 1 was a compulsive food seeker. She said Resident 1 grabbed and ate the applesauce when it was left unsupervised on the top of the medication cart. She said she was responsible for checking each tray on the cart before the Certified Nursing Assistants (CNAs) delivered the trays.

LN 1 said at about 8 A.M. on 10/28/12, "I was in a hurry." Resident 1, "Stood in front of the food cart. I wanted to make sure he did not grab any other resident's food. I made a mistake. I was not careful to match the diet card with the food on the plate, when I checked the tray," for Resident 1. LN 1 said she handed the tray to CNA 1 to move Resident 1 away from the other food trays.

CNA 1 said on 10/31/12 at 12:30 P.M., she was assigned to care for Resident 1 on the day shift on 10/28/12. CNA 1 said she was aware Resident 1 wandered throughout the facility and grabbed food from others. She said she was aware Resident 1 was only to have chopped food. CNA said she knew Resident 1 was on 1:1 supervision for meals.

CNA 1 said LN 1 handed her Resident 1's breakfast tray from the cart on 10/28/12 at about 8:05 A.M. She told Resident 1 she had his food and he immediately followed her to his room. CNA 1 said she usually checked the trays when she got into the rooms. She said as she lifted the plate cover, Resident 1 grabbed 2 pancakes and 2 uncut sausage patties and stuffed them into his mouth. CNA 1 said Resident 1 walked out of his room and into the hallway. CNA 1 followed behind him with some milk, intending to encourage Resident 1 to drink the milk. CNA 1 said she immediately told LN 1 that Resident 1 grabbed his food and put it into his mouth. Within a minute or two, Resident 1 collapsed on the floor in the hallway, in front of his room. CNA 1 said she called for help.

LN 1 said on 10/31/12 at 1:35 P.M., she was in the hallway on 10/28/12 at about 8:10 A.M. and saw Resident 1 fall to the floor. She rushed to Resident 1. He was foaming at the mouth and he looked pale. LN 1 she said she put on gloves and swept the Residents mouth. Some food was removed. LN 1 said she tried to do the Heimlich maneuver (emergency technique to unblock the airway) on the floor, but it was not successful. Resident 1 was not breathing and his skin color was blue. LN 1 said she started CPR (cardiopulmonary resuscitation -mouth to mouth breathing and chest compressions). Another staff member called a "code blue" (resident not breathing and CPR initiated). Other staff members arrived and Resident 1 was carried from the hallway, outside of his room, to his bed. The physician was notified and 9-1-1- was called, while the CPR continued.

According to the facility records, the Emergency Medical Technicians (EMTs) arrived at 8:20 A.M. and took over the care of Resident 1. The EMTs transported Resident 1 to the acute care hospital.

According to the hospital records, the Emergency Room (ER) physician removed food from the throat of Resident 1, to establish an airway. Resident 1 was unable to be resuscitated and was pronounced dead, due to airway obstruction.

On 10/31/12 at 12:30 P.M. the Registered Dietician and Food Services Manager cooked a sausage patty, the same sausage as prepared on 10/28/12 for Resident 1. The patty was circular and measured 3 inches by 3 inches.

According to the facility undated policy titled, Choking Prevention, "Prior to serving the trays to the Residents have the license nurse assigned to the dining room to check that all the meal matches the diet slip ...Certified Nursing Assistants (CNAs), are to double check meals after the nurse has checked the tray for any missed items or wrong diet in the tray that the nurse may have over looked."

According to the facility diet manual, Healthcare services Group I, Diet Manual Third Edition 2011, a Mechanical Chopped Diet consists of: Meats chopped to the consistency of small dice (1/2 inch).

According to the Medical Examiner's report dated 12/24/12, Resident 1 expired due to airway obstruction and aspiration (inhalation) of food.

The facility failed to follow the physician's orders for a chopped diet. The Cook, the Dietary Line Checker, the Licensed Nurse and the Certified Nursing Assistant did not verify that the prescribed diet, in the correct consistency, was checked prior to bringing the meal tray into Resident 1's room. Resident 1 was known to have behaviors, in which he immediately grabbed for food and stuffed the food into his mouth. As a result, Resident 1 grabbed 2 pancakes and 2 uncut whole sausage patties from his breakfast tray and put all 4 items into his mouth. The resident choked on the food and died.

This violation presented an imminent danger that death or serious harm to the patients or residents of the long-term health care facility would result therefrom, or a substantial probability that death or serious physical harm to patients or residents of the long-term health care facility would result therefrom, and was a direct proximate cause of the death of the a patient.