Hancock Park Rehabilitation Center
505 N. La Brea Ave, Los Angeles CA 90036
Citation Number: 940006956
Citation Date: 05/03/2010
Violation Date: 05/06/2008
Class: AA
Penalty: $ 100,000

On 5/19/08, an 84 year old resident died from aspiration pneumonia, 13 days after being hospitalized because the staff inserted a feeding tube into his lungs, The nursing staff had reinserted the resident's naso-gastric tube after it came out on 5/6/08, however, no one admitted to reinserting it or checking to ensure its proper placement. As a result, the subsequent feedings flowed directly into the resident's lungs, causing his death. The facility was cited for failing to ensure and verify correct placement of the feeding tube when it was reinserted and each time feedings and medications were administered.