Metropolitan State Hospital D/P SNF
11401 S. Bloomfield Avenue, Norwalk, CA 90650
Citation Number: 170006836
Citation Date: 11/18/2010
Violation Date: 9/29/2007
Class: AA
Penalty: $ 100,000


72311 (a)(1 )(2) Nursing Service General
(a) Nursing service shall include, but not limited to the following:
(1) Planning of patient care which shall include at least the following:
(2) Implementing of each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan.

72523(a) Patient Care Policies and Procedures (a) Written patient care policies shall be established and implemented to ensure that patient related goals and facility objectives are achieved,

The facility failed to:

1. Implement the care plan for Resident 1 by failing to monitor Resident 1 for choking during meal time and
2. Implement the Foreign Body Airway Obstruction patient care policies for Resident 1 by failing to closely observe and monitor Resident 1 during mealtime and failing to open the airway and remove foreign body, if seen, and begin CPR ..

On September 29, 2007, Resident 1 was found in his room, face down, and unresponsive immediately after evening meal. Resident 1 had previously been identified as having eating difficulties and was on choking precautions.

A review of the clinical record for Resident 1 on October 10, 2007 revealed a 61 year-old male who was admitted to the facility with diagnoses that included schizophrenia, poly substance dependence hypertension and at risk for choking secondary to being edentulous (toothless). A review of a quarterly well ness and recovery plan dated September 29, 2007 revealed that Resident 1 was unable to take care of himself, confused and mute.

Further record review revealed Resident 1 's care plan required mechanical soft diet due to the risk of choking. Specifically, Resident 1 's Wellness and Recovery Plan (WRP care plan) initiated March 9, 2004 indicated under intervention Nsg (Nursing) will monitor the resident during each meal as a choking precaution and under intervention Nsg will assist him at mealtimes to encourage adequate intake of meals and to monitor for choking.

Review of the facility's policy on Foreign Body Airway Obstruction Managemen/Choking" of individuals/residents on choking precautions dated November 2007 revealed the following directives under "Nursing Responsibilities ":

1. Closely observe Individuals during meal times
2. Closely observe Individual's who have identified eating difficulties/choking and
6. Early recognition of Airway Obstruction and
7. Prompt action to remove foreign body to restore adequate breathing.

The section titled, "Foreign Body Airway Management" dated November 2007 revealed the following directives under "Emergency Management for Unconscious Victim":

A. If assistance is available, send them to dial "6" and bring back the AED (Automated External Defibrillator). If alone, dial "6". Tell the operator the Individual's name, Unit and the nature of the emergency and get the AED. Apply the AED as soon as it is available.

B. Open the airway, remove the object if you see it, and begin CPR with one exception: every time you open the airway to give breaths, open the victim's mouth wide and look for the object. If you see an object, remove it. If you do not see an object, keep doing CPR.

During interview on July 8, 2008 at 11 :05 a.m., Licensed Staff 2 stated that Resident 1 had the tendency to grab other residents' food during meal times and consume it quickly. Licensed Staff 2 stated that on September 29, 2007, Resident 1 ate in the day hall instead of the dining room. She stated that he was served his meal after 6 p.m. but did not know when he completed his dinner and went to his room. Licensed Staff 2 confirmed that Resident 1 did not receive close supervision during his evening meal on that date and the clinical record for Resident 1 did not indicate or provide documentation that the resident was monitored during the evening meal on that date.

During interview on July 8, 2008 at 2:30 p.m., Licensed Staff 1 stated that on September 29, 2007 at 7 p.m., she was passing medications on the unit and observed Resident 1 laying on his bed with his face down. According to Licensed Staff 1, Resident 1 was unresponsive and "appeared flaccid". Licensed staff stated that she went and called for help.

Review of the Los Angeles County Fire Department Paramedics report dated October 29, 2007 showed that the Paramedics were dispatched at 7:09 p.m. and arrived at the scene at 7:19 p.m. Resident 1 was found lying on the bed. The resident was last seen 5 minutes prior by staff eating. Staff attached AED but did not initiate CPR. No CPR was administered for approximately 15 minutes until the Fire Department arrived. Fire Department initiated CPR. Upon attempted intubation (inserting of breathing tube down airway), food was found in the patient's airway. The resident was suctioned and then intubated on first attempt and was transferred to acute hospital at 7:38 p.m. Resident 1 was pronounced dead at the acute hospital on September 29, 2007 at 7:45 p.m. The cause of death was asphyxiation due to choking.

Review of the County of Los Angeles Coroner's report entitled "Autopsy Report" dated October 2, 2007 documented "A food bolus is noted in the laryngeo pharynx; the pharynx and larynx are not otherwise remarkable." The Coroner described the manner of death as: "Asphyxiation due to or as a consequence of choking."

The Autopsy report indicates that the cause of death was airway obstruction secondary to food bolus. The manner of death was asphyxia due to airway obstruction.

The facility failed to implement the care plan for Resident 1 by not monitoring Resident 1 at mealtime to prevent choking. The facility also failed to implement its own patient care and policies and procedures by failing to closely observe an individual identified as having choking difficulties during a meal and failing to follow its policy for Foreign Body Airway Management Emergency Management, Unconscious Victim to open the airway and remove foreign body if seen and begin CPR.

These regulation violations, jointly or separately, presented either 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 death to the resident of the long-term health care facility.