Emeritus At Yorba Linda
17803 Imperial Highway, Yorba Linda, Ca 92886
Citation Number: 060008760
Citation Date: 08/09/2011
Violation Date: 1/30/2011
A resident died after choking on a large piece of ham that was served to her for lunch in bed on 1/30/2011. Due to a history of stroke and difficulty chewing and swallowing, the resident's doctor had put her on a special soft, finely chopped diet and ordered that she be up in the dining room for all meals. Her care plan called for supervision during meals and help with her dentures. These orders and precautions were not followed during the meal that led to her death. The nursing assistant who delivered the meal tray to her bedside table reported she "forgot" to place the upper denture in the resident's mouth before that meal. After passing out trays, the nursing assistant returned and found the resident foaming at the mouth, with her skin gray and purple. A licensed nurse responded and unsuccessfully attempted the Heimlich maneuver. Then an RN and paramedics were summoned. The resident was described as purple, cyanotic, and nonresponsive. She was hospitalized and died six days later due to cardiopulmonary and respiratory arrest due to choking. The emergency room physician who removed the large piece of ham from her airway reported that the EMTs, paramedics and he did not have any knowledge that the resident may have been choking. The resident's family member also reported that the facility did not tell her that the resident may be choking when it called her about the crisis. The facility was cited because it failed to provide the resident with her dentures, supervision and finely chopped meat as ordered, causing her to choke to death.