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"Patient who choked to death costs Crestwood $100,000 fine"

Times Herald

By RACHEL RASKIN-ZRIHEN/Times-Herald staff writer
Article Launched: 09/03/2008 08:11:22 AM PDT

A Vallejo nursing home has been slapped with the most serious possible type of citation after a person in its care choked to death.

Patricia McGinnis, executive director of a long–term care facility advocacy group, said Crestwood Manor’s category AA citation carries a $100,000 penalty imposed by the state Department of Public Health.

No one from Crestwood, a 246–capacity skilled nursing home on Tuolumne Street, returned calls for comment Tuesday, but McGinnis said most facilities faced with such large fines appeal the citation.

"I’ve never seen one not appeal it, and usually, they end up paying far less than 100 percent of the fine," she said.

The citation stemmed from an October incident involving a man in a wheelchair who choked on a cinnamon roll.

The man, who suffered from dementia and was on a pureed diet, was in the dining room during snack time when the incident occurred, according to information from the California Health and Human Services Agency. It was not known how the man got the roll, which was available in a vending machine, the information notes.

The man was described as the facility’s "number one high risk for choking" because he had no teeth and also had a history of stuffing food in his mouth, according to the information.

The man’s death was deemed to be the direct result of negligent care, said McGinnis of the California Advocates for Nursing Home Reform. The facility had another AA citation in 2004. But Crestwood isn’t the only local nursing home to have been cited. In fact, of Vallejo’s five nursing care facilities, only Sutter Solano Medical Center’s has not been cited in the past five years, McGinnis said.

The Vallejo Care Center got a class B citation in 2006, a class A citation in 2005 and four class Bs in 2004, McGinnis said. Evergreen Health Care Center of Vallejo, Heartwood, got a class A citation in 2006 while Everygreen Health Care Center Springs Road got an AA citation in 2004 and an A citation in 2005, she said. The difference between an A and an AA citation is usually that a death resulted from the AA–precipitating incident, McGinnis said. AA citations are rare, but preventable deaths and injuries at nursing homes, aren’t, she said.

"It’s pretty awful," she said. "These places are supposed to have the staff to prevent this sort of thing."

Citations like the one issued to Crestwood Manor are mostly about raising awareness.

"In nursing homes in California, there continues to be far too many preventable deaths," McGinnis said. "Every time you see something like that, it breaks your heart. You think of the families who place their loved one, and pay for it, thinking they’ll get the care they need, and, too often, they don’t."