The Orchard - Post Acute Care
12385 E. Washington, Whittier, CA 90606
Citation Number: 940008202
Citation Date: 8/10/2011
Violation Date: 11/?/2008
Class: AA
Penalty: $ 75,000

In 2008, a 78 year old resident died due to complications after a nurse incorrectly inserted a feeding tube (gastrostomy tube) into the peritoneal cavity outside his stomach rather than into his stomach. The resident was hospitalized the same day after complaining of severe abdominal pain and arrived in critical condition with extreme pain and bleeding from the tube site. X-rays revealed that the tube had been misplaced. The resident required surgery, was put on a ventilator due to respiratory failure, and was treated for septic shock, pneumonia and persistent renal dysfunction. After his condition continued to decline, he was put on comfort care and died 6 days after the tube was wrongly inserted. The facility was cited because its actions were a direct cause of the resident's death.