Inland Valley Care and Rehabilitation Center
250 W. Artesia, Pomona, CA 91768
Citation Number: 950005577
Citation Date: 5/18/2009
Violation Date: 1/28/2008
Class: AA
Penalty: $ 100,000

On February 8, 2008, a resident died stemming from a nurse's failed reinsertion of a feeding (nasal gastric) tube on January 28, 2008 without a valid physician's order. Instead of inserting the tube into her stomach, the nurse perforated the resident's right lung and the tube ended up in her chest cavity. After failing to detect this life-threatening injury, the nurse resumed administering feedings, medications and fluids through the misplaced feeding tube. The contents emptied into the resident's chest cavity, causing respiratory distress, hospitalization the following morning and, ultimately, her death. X-rays taken at the hospital and a death certificate by the coroner verified that the perforation of the resident's lung led to her death. The facility failed to notify the attending physician that the feeding tube was out, failed to ask the physician if the tube should be reinserted, and failed to determine if the physician wanted an x-ray to assess whether the tube was properly inserted.