P.O. BOX 1493, ELDRIDGE, CA 95431
Citation Number: 150003148
Citation Date: 8/13/2007
Violation Date: 10/22/2005
Class: AA
Penalty: $ 90000.00


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

(Use F224 for deficiencies concerning mistreatment, neglect or misappropriation of resident property.)

The facility failed to comply with the above regulation by failing to ensure that Client 1 received appropriate services to prevent the swallowing of three lemon glycerin swabs. This failure lead to Client 1 sustaining a puncture wound between his esophagus and aorta, resulting in his death.

Review of Interdisciplinary Notes (IDNs) dated 10/22/05, Staff A stated the following: At 9:15 (a.m.): "When I got inside Rm (room) 121, I saw [Client 1] vomiting c (with) blood, I called the clinic person right away, as soon as I saw a lot of blood. ... "Staff B stated in the IDNs, at 9:15 (a.m.)," We saw he throw-up the glycerin swab as well. " At 10:45 a.m.: Staff C stated, " Staff observed an emesis from [Client 1] containing frank (obvious, clearly evident) blood ... appeared [Client 1] threw up a toothette swab & (and) swab end was covered c (with) clotted blood." Client 1 was transferred to a local General Acute Care Hospital (GACH) at 9:35 a.m., on 10/22/2005. At 0315 (3:15 a.m.) on 10/23/2005, Sonoma Developmental Center was notified that Client 1 expired at 0230 (2:30 a.m.)

Review of Client 1's record stated that he was 25 years old with diagnoses which included cerebral palsy (condition affecting control of the motor system due to lesions in various parts of the brain), quadriparesis (partial paralysis of both arms and both legs), epilepsy, dysphagia (difficulty in swallowing), profound mental retardation, history of esophagitis (inflammation of the esophagus), GERD (gastric esophageal reflux disease - backward flow of stomach digestive juices into the esophagus), and a history of pneumonia due to aspiration (inhalation of food particles and/or liquid into the lungs). Review of Client 1's most recent full Minimum Data Set (MDS), dated 06/01/2005, stated that he was totally dependent on staff for all Activities of Daily Living, was confined to a special wheelchair, had highly impaired vision, and a limitation in the use of both arms with a partial loss of voluntary movement.

Review of Client 1's Resident Assessment Protocols (RAPs), dated 06/08/2005 contained in his Individual Program Plan (IPP), stated that he had a Jejunostomy feeding tube (a tube in the upper portion of the small intestine to deliver food and medications) due his chewing problems, dysphagia, and hand dexterity problems. The RAPs further stated that "oral hygiene is provided daily by staff. ... [Client 1] has an order to use a moistened toothette to gently clean the backside of the top front teeth and gums every AM and PM when teeth are brushed. ... Staff discussed the reason for the use of the toothettes, 'it is due to relation to his thumb to mouth activity', that this was soothing intervention and would provide moisture if dry and irritated area was present." Physicians Orders dated 10/15/2005 show an order which reads, " Use moistened toothette to gently clean the backside of the top front teeth + the gums behind top front teeth, every AM & PM, when teeth are brushed daily" . Review of Client 1 ' s Medication and Treatment Record for SEP/OCT (September/October) 2005, a period of 31 days, revealed that the client receive oral care twice daily with a moistened toothette, as noted by staff initials. Interview with Staff F revealed that the equipment required to give oral care would have been set on the client's "side table and not on the bed."

The Autopsy findings, dated 10/25/2005, stated the following: " 1. Massive gastrointestinal hemorrhage (MGH): A. Acute traumatic aorto (main artery leaving the heart)-esophageal fistula (wound between the aorta and the esophagus) with granulation tissue (formation in wounds of small, rounded fleshy masses) between descending thoracic aorta and esophagus. B. Two plastic-handled cotton swabs in upper stomach.... Cause of Death: Acute Massive Upper Gastrointestinal Hemorrhage. "

Under Comments, in the Autopsy findings, the following was noted: "This 25 year old man with cerebral palsy, quadriplegia with limb contractures, severe mental retardation...died as a result of a Massive Gastrointestinal Hemorrhage due to a traumatic aorto-esophageal fistula (an opening between the aorta and the esophagus) occurring hours prior to his death and initiated days prior as the result of esophageal injury from a plastic-handled cotton-tipped swab. The decedent's conditions of quadriplegia with body and limb deformity related to cerebral palsy rendered him, in my opinion, very unlikely to have introduced the swabs to himself."

During an interview with Staff D, on 05/24/2006 at 11 a.m., it was stated that: " [Client 1] had no fine motor skills of his hands, could not grasp anything and had only spastic hand to mouth movements. " During an interview with Direct Care Staff E, on 05/24/2006 at 11:30 a.m., it was stated that: " [Client 1] would pick at his teeth with his right thumb, he could swallow his oral secretions, but nothing was given by mouth. "When Staff E was asked if Client 1 could push anything into his mouth, Staff E further stated that: " If a toothette had been left in [Client 1's] mouth, it would have been possible for him to push it further in."

The facility failed to ensure that Client 1 received care to prevent the swallowing of lemon glycerine swabs when he was totally dependent upon staff for all aspects of daily care. Based on record review and staff interview, this client was not capable of placing the swabs into his mouth due to the lack of fine motor skills. This lack of care led to the client suffering a puncture wound of the esophagus through to the aorta, resulting in the client bleeding to death internally.

This facility failure presents 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 was a direct proximate cause of death to the patient or resident of the long-term health facility.