TWIN OAKS HEALTH AND REHABILITATION CENTER
1200 SPRINGFIELD DR, CHICO, CA 95928
Citation Number: 230004700
Citation Date: 2/21/2008
Violation Date: 12/7/2007
Class: AA
Penalty: $ 100000.0

A 98 year old female resident was admitted to the facility on 2/12/07 with an admission order for a soft waist belt restraint in her wheelchair. The resident also used a pummel cushion to prevent her from sliding forward, but the cushion was discontinued on 11/07 to reduce the number of restraints. On 12/7/07, the resident began sliding down in her wheelchair more frequently and further down than normal. She was repositioned at least six times that evening. Two CNAs were going to put her to bed when another resident's family member requested for their relative to be put to bed first. The CNAs left the resident in her wheelchair in the doorway to her room. 20-30 minutes later, the CNAs noticed the door to the resident's room closed. The CNAs entered the room and found the resident lying on the floor at the foot of her wheelchair with the waist belt under her chin, still connected to the wheelchair. The resident had choked to death. The facility was cited for failing to keep the resident safe from a harmful accident by not providing adequate supervision.