HEALDSBURG DISTRICT HOSPITAL D/P SNF
1375 University Ave Healdsburg, CA 95448
Citation Number: 110009753
Citation Date: 1/24/2014
Violation Date: 6/5/2012
Class: AA
Penalty: $50,000

On 6/5/12, a nurse at Healdsburg District Hospital SNF improperly inserted a male resident's G-tube outside of his stomach wall, pumping food and water into his abdominal cavity, and causing him to go into septic shock and die. The nurse had found the resident with a disconnected G-tube, and reinserted the tube with some difficulty, stating that she felt a "pop" before the tube was fully replaced. She heard air to the left of the insertion site, rather than the right, where it should have been, but did not request an x-ray to check the placement. Within 24 hours, staff observed the resident profusely sweating, shaking and cold with low blood pressure and gray coloration. Still, staff continued to monitor the resident, without sending him to the hospital until 6/8/12. He was diagnosed with septic shock and died on 6/17/12.