PALM TERRACE HEALTHCARE & REHABILITATION CENTER
24962 CALLE ARAGON, LAGUNA HILLS, CA 92653
Citation Number: 060004611
Citation Date: 2/1/2008
Violation Date: 3/17/2007
Class: AA
Penalty: $ 75000.00

On 3/17/07, a resident, who suffered from dementia, choked on a piece of meat when the facility left her to eat alone in her room without any supervision, despite the fact she was observed to be tired and lethargic. She was hospitalized and died three days later due to airway obstruction. The hospital discovered that, prior to choking, she had overdosed on morphine, even though her physician had not prescribed this medication. The coroner found very high levels of morphine in her blood and concluded that morphine had been administered over a period of time prior to the choking incident. The coroner stated that "there appears to be a high index of suspicion that the morphine played a significant role in the aspiration event." A homicide division detective reported that his office had not been able to determine who administered the morphine to the resident.