Seton Medical Center
1900 Sullivan Ave., Daly City, CA 94015
Citation Number: 220011305
Citation Date: 3/4/2015
Violation Date: 1/1/2014
Class: AA
Penalty: $ 75,000

A female resident with pneumonia and respiratory failure went several minutes without breathing when her tracheostomy tube was left with an inflated cuff, causing an airway obstruction. Even after the resident was discovered not breathing and without a pulse, CPR was delayed by several minutes because the facility staff had to investigate her "code status." The resident was subsequently revived but left in a persistent vegetative state. Her family discontinued active treatment and the resident died shortly thereafter. The facility was cited for failing to follow its policy and procedure and the manufacturer's recommendation for tracheostomy care in a way that presented substantial probability of death or serious harm.