Seton Medical Center
1900 Sullivan Ave., Daly City, CA 94015
Citation Number: 220008904
Citation Date: 01/12/2012
Violation Date: 6/24/2011
Class: AA
Penalty: $ 100,000

An 81 year old resident who suffered from chronic respiratory failure, died due to asphyxiation on 6/24/11 as a result of obstruction to her tracheostomy tube. The obstruction was caused when a nurse failed to remove a cap while changing the tracheostomy tube. The cap prevented the resident from receiving oxygen. The manufacturer's directions advised that the cap must be removed before use and warned that failure to do so may result in death. A representative for the manufacturer said that "it is like suffocating the patient" if the cap is not off in this situation because a patient cannot exhale. The Coroner's report stated that the resident died from asphyxiation due to obstruction of the tracheostomy tube related to the failure to remove the cap. The facility was cited because the facility's failure was a direct proximate cause of her death.