Goldstar Rehabilitation and Nursing Center of Santa Monica
1340 15th Street, Santa Monica, CA 90404
Citation Number: 910007605
Citation Date: 01/10/2011
Violation Date: 4/16/2009
Class: AA
Penalty: $ 100,000

The following reflects the findings of the Department of Public Health during a Complaint Investigation visit:

CLASS AA CITATION -- DIETARY
91-1758-0007605-S
Complaint(s): CA00185685

Representing the Department of Public Health: , R.N.

The inspection was limited to the specific facility event investigated and does not represent the findings of a full inspection of the facility.

CALIFORNIA CODE REGULATIONS TITLE 22

72339 Dietetic Service - Therapeutic Diets Therapeutic diets shall be provided for each patient as prescribed and shall be planned, prepared and served with supervision and/or consultation from the dietitian. Persons responsible for therapeutic diets shall have sufficient knowledge of food values to make appropriate substitutions when necessary.

72311(a)(2) Nursing Service-General

(a) Nursing service shall include, but not be limited to, 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.

72311(c) Nursing Service-General

(c) Licensed personnel shall ensure that patients are served the diets as prescribed by attending physicians.

On May 6, 2009, at 1:35 p.m., an entity reported event was investigated regarding a patient who choked while eating dinner.

Based on interview and record review the facility's nursing staff failed to:

1. Provide Patient A with a prescribed therapeutic diet (mechanical soft) (a diet designed for individuals who have difficulty chewing or swallowing, in which the meats are ground or chopped as tolerated), which was ordered by the physician on December 11, 2008. The patient was eating dinner at an activity-sponsored event (a candlelight dinner), at the facility, when he began to choke on meat that had been prepared by the activities director (AD) at her home, without adherence to the patient's prescribed diet. The patient lost consciousness for approximately 10-15 minutes while efforts were made to resuscitate him. He was resuscitated and transferred to an acute care hospital and expired 7 days after admission, from severe anoxic encephalopathy (altered brain function and structure from the absence of oxygen).

2. Implement a plan of care, which indicated that Patient A was on a mechanically altered diet, and that the facility would provide him with a diet as ordered, so that he would have no signs and symptoms of aspiration/choking.

3. Ensure Patient A was served a diet as prescribed by the attending physician.

These failures resulted in the death of Patient A, due to severe anoxic encephalopathy, following an obstruction of the airway, by a food bolus (choking).

A review of Patient A's Admission Records indicated he was a 60-year-old male, who was admitted to the facility on July 28, 2008, with diagnoses that included multiple sclerosis (nervous system disease that affects the brain and spinal cord) and hypothyroidism (low thyroid hormone).

According to the Minimum Data Set (MDS) Assessment (a standardized comprehensive assessment of the Patient's problems and conditions), dated August 8, 2008, Patient A required limited assistance to eat, had a chewing problem and was on a mechanically altered, therapeutic diet. The patient experienced loss of some or all of his natural teeth and did not use dentures or partial plates.

Patient A's physician ordered a therapeutic, mechanical soft diet on December 11, 2008.

A Care Plan developed July 30, 2008, and revised February 2009, indicated Patient A was on a mechanically altered diet. A goal for the patient was to have no signs and symptoms of aspiration/choking daily for three months. An approach developed to ensure the patient met this goal was for the facility to provide a diet as ordered, encourage adherence to the diet, dietary/nursing to assess the texture of his food, allow enough time for him to chew and swallow, monitor his tolerance to the food and swallowing during meals, monitor for signs and symptoms of choking/aspiration.

A Licensed Nurse's Progress Note, dated April 16, 2009, at 5:20 p.m., indicated Patient A was on the sixth floor, of the facility, eating a candle light dinner when the staff observed him coughing and choking. The nursing staff was called to assist the patient who was observed turning blue.

On May 6, 2009, at 2:25 p.m., the AD stated Patient A had just started eating and had vegetables in his mouth. The AD also stated she believes the patient choked on the pork chop, which was boneless, thick and breaded.

On May 6, 2009, at 2:50 p.m., the MDS nurse stated Patient A grabbed his throat indicating he was choking. She performed the Heimlich maneuver (abdominal thrusts) while the patient was sitting in his wheelchair. The MDS nurse stated the patient became limp and they placed him on the floor. The MDS nurse indicated Licensed Vocational Nurse 1 (LVN 1) performed abdominal thrust two times and the meat was seen at the back of the Patient's throat. The paramedics arrived and pulled meat out of Patient A's throat using a long instrument.

On May 6, 2009, at 3:08 p.m., LVN 1 stated the MDS nurse was performing the Heimlich maneuver on Patient A while he was sitting in his wheelchair, he became limp and they placed him on the floor. Abdominal thrusts were started and the patient took a deep breath. The staff saw meat at the back of Patient A's throat, at that time the paramedics arrived and pulled a 2 inch piece of meat from the resident's mouth with a long pair of tweezers. She stated there were other pieces of meat that came out of the Patient's mouth (4-5 pieces) that ranged in size from 12 inch to 1 inch in length and thickness. She stated the patient was on a special diet. The activity staff selected the residents who would attend the candle light dinner without asking the nurses about the residents' eating restrictions.

On May 6, 2009 at 3:55 p.m., the Administrator stated the residents requested to have pork chops at their candle light dinner, however, the facility's kitchen is Kosher (foods prepared according to dietary law) and they don't serve pork. The AD offered to cook the pork chops at her home.

On May 7, 2009 at 11:15 a.m., the AD stated she did not know Patient A had dietary restrictions, because she always saw him eating everything. She stated she would not have invited him to the candle light dinner if she knew he had food restrictions. She stated she had not been trained to prepare food for special diets, i.e., puree, mechanical soft etc. The pork chops she cooked were approximately 12 inch to 1 inch thick, chunky but were also kind of shredded.

On May 7, 2009, at 11:30 a.m., the Assistant Activities Director (AAD) stated Patient A was on a regular diet (when in fact, the patient was on a mechanical soft diet) and they only allowed residents on a regular diet to attend the candle light dinner. He stated he asked the patient if he needed assistance cutting up his meat, the patient refused twice. He stated the patient was a fast eater and wanted to cut up his own meat. When the patient began to choke the Heimlich maneuver was performed. The paramedics arrived and removed a large piece of meat from the resident's throat that was approximately 3-4 inches in length, and 1 inch thick. There were also smaller pieces of meat on top of the large piece of meat that were removed from the patient's throat.

On May 7, 2009, at 12:05 p.m., the Dietary Supervisor (DS) stated the meat for a mechanical soft diet should be cut up fine because they do not want any of the patients to choke. He stated the pork chops were not cooked at the facility, but they were brought to the kitchen by the AD. The AD heated the pork chops in the kitchen and then they were taken to the activity area. The dietary staff only prepared the vegetables and other food that went with the pork chops. The activity department preferred to do their own presentation of the food at the candle light dinners. The dietary staff did not serve the patients or put the food on their trays, this was done by the activity staff. He stated normally they choose the patients who are alert, oriented and are on regular diets for the candle light dinner. They (dietary staff) then prepare the food according to the patient's restrictions. This time the dietary staff did not do that because they did not provide the food.

A review of the Fire Department Emergency Medical Services Report, dated April 16, 2009, indicated the paramedics reached Patient A at 5:22 p.m., where they found him lying supine (on his back) on the floor, after having choked on food. The staff attempted the Heimlich maneuver prior to the paramedic's arrival and CPR (cardiopulmonary resuscitation) was in progress when the paramedics arrived, a large piece of meat was removed by one of the paramedics. The report indicated the resident's pupils were fixed and dilated. He was not alert, was apneic (absence of breathing), did not open his eyes, there was no motor response; he was non-verbal and cyanotic (bluish color of the skin).

On February 9, 2010 at 4:15 p.m., Paramedic 1 stated he used a laryngoscope (instrument used to view the airway) to visualize Patient A's throat and forceps to move his tongue out of the way. He saw an object at the back of the patient's throat and began to pull it out. He did not know at that time what it was, (was told later it was a piece of meat), but it looked like a wadded up napkin/paper. He began to remove the object and was surprised at how much kept coming out. He did not recall the exact size of the objects removed but remembers there were a lot of smaller pieces and at least one larger piece.

According to the Inpatient Death Summary dated April 23, 2009, from the acute care medical center, where Patient A was transferred and later expired, the final di agnosi s i ncl uded st at us post-cardiopulmonary arrest from food choking, anoxic encephalopathy and post cardiac arrest myoclonus (a sudden twitching of muscles or parts of muscles, without any rhythm or pattern, occurring in various brain disorders).

The Brief Hospital Course indicated the patient choked on his food on the day of admission (April 16, 2009). He was cyanotic and the paramedics were called, the patient was resuscitated in the field. The length of time he was cyanotic was approximately 10-15 minutes. Upon arrival in the intensive care unit, the patient had significant myoclonic jerking. He was loaded (a large amount administered as the initial dose) with Fosphenytoin, (used for treating certain types of severe seizures, e.g., status epilepticus), and was given Ativan (anti-anxiety agent (benzodiazepines, mild tranquilizer) used for the relief of anxiety, agitation and irritability) with resolution of his myoclonus. He underwent an EEG (a test that measures and records the electrical activity of the brain), which showed severe diffuse slowing consistent with anoxic injury (occurs in cases of severe lack of oxygen to the brain) x 2 and was placed on mechanical ventilation (a method to mechanically assist or replace spontaneous breathing- involving a machine called a ventilator to support his breathing), on April 16, 2009, when he was admitted to the hospital for choking. His repeat electroencephalogram (tracing of electrical activity in the brain) (EEG), did not show any seizure focus and was again consistent with severe anoxic encephalopathy. The patient did not have any significant spontaneous movement except for reflexive foot movement. After extensive discussion between the neurology physicians, the ICU (intensive care unit) primary team, and the patient's family there was consensus that the patient would not wish to continue with life support. After extubation (removal of the tube), the patient was placed on morphine (narcotic pain reliever) for comfort protocol. He expired the morning of April 23, 2009.

The County of Los Angeles - Registrar-Recorder/County Clerk Certificate of Death, filed on May 14, 2009, indicated Patient A's cause of death was anoxic encephalopathy and choking.

According to the facility's policy on Choking a choking person's airway may be completely or partially blocked. A complete blockage is an urgent medical emergency. Without oxygen, permanent brain damage can occur in as little as 4 minutes.

An additional facility policy on the Mechanical Soft Diet indicated the diet is designed for individuals who have difficulty chewing or swallowing. The foods are the same as the regular diet, but meat is served ground or chopped as tolerated.

A facility policy on Therapeutic Diets indicated routine menus (without therapeutic purpose) are planned by the food service manager, and approved by a registered dietitian for nutritional adequacy. The registered dietitian for therapeutic diets will modify the regular menu, with input form the dietary manager for feasibility of kitchen production.

On April 16, 2009, at approximately 5:10 p.m., Patient A was eating dinner at an activity-sponsored event (a candlelight dinner), at the facility, when he began to choke on meat that had been prepared at the home of the activities director without adherence to the resident's prescribed diet. The patient lost consciousness for approximately 10-15 minutes while efforts were made to resuscitate him. He was eventually resuscitated and transferred to an acute care facility where he later expired, 7 days after admission, from severe anoxic encephalopathy (altered brain function and structure from the absence of oxygen).

Therefore, the facility failed to:

1. Provide the patient with a prescribed therapeutic diet (mechanical soft), that was ordered by his physician. The patient was eating dinner at an activity-sponsored event (a candlelight dinner), at the facility, when he began to choke on meat that had been prepared at the home of the activities director without adherence to the resident's prescribed diet. The patient lost consciousness for approximately 10-15 minutes while efforts were made to resuscitate him. He was eventually resuscitated and transferred to an acute care facility where he later expired, 7 days after admission, from severe anoxic encephalopathy (altered brain function and structure from the absence of oxygen).

2. Implement the patient's plan of care, which indicated that Patient A was on a mechanically altered diet, and that the facility would provide him with a diet as ordered, so that he would have no signs and symptoms of aspiration/choking.

3. Ensure Patient A was served a diet as prescribed by the attending physician.

These failures resulted in the death of Patient A, due to severe anoxic encephalopathy, following an obstruction of the airway, by a food bolus (choking).

These violations, jointly, separately, or in any combination, 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 were a direct proximate cause of death of the patient.