Tustin Care Center, Inc.
1051 Bryan Avenue, Tustin, Ca 92780
Citation Number: 060006323
Citation Date: 6/26/2009
Violation Date: 3/14/2009
Class: AA
Penalty: $ 50,000

At admission in October 2008, a resident was alert, ambulatory and able to feed himself. His health declined during his stay, and by February 2009 he was very weak, unable to walk, incontinent, and out of bed for meals only. On 3/14/09, he was taken by wheelchair to the dining room for lunch, where he began choking on his meal. A nurse performed the Heimlich maneuver and CPR. Paramedics were summoned and took him to the hospital, where he died the same day. The Coroner's autopsy report states that the cause of death was asphyxia due to choking on food. A solid bolus of food was found in his trachea. The facility was cited because it failed to provide an ongoing assessment of the resident's functional level and failed to assess his ability to tolerate a regular diet consistency once he continued to decline. These failures led to his death.