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"Nursing home cited and fined over death"

Original source: by the Union-Tribune

Agency points to poor supervision

By Kristina Davis
Union-Tribune Staff Writer
2:00 a.m. March 13, 2009

ESCONDIDO — An Escondido nursing home yesterday received the state's most severe citation and a $90,000 fine after an investigation found that poor treatment and supervision resulted in a resident choking to death last year.

California issues an average of 20 “AA” citations each year, said Al Lundeen, a spokesman for the agency. That means in any given year that less than 1.5 percent of the roughly 1,400 skilled nursing facilities statewide have incidents serious enough to trigger this level of censure.

Escondido Care Center, a 180-bed facility on East Mission Avenue, failed to adjust the patient's meal plan to meet his changing dietary needs, according to a report released by the California Department of Public Health.

The man, whose named was not released, suffocated Nov. 30 when food became stuck in his windpipe and the right main bronchial stem. He was eating a lunch of beef with barbecue sauce, mashed potatoes, and steamed cabbage and carrots.

His physician had put him on a strict diet to avoid problems with chewing and swallowing.

On two occasions in November, the facility's dietary supervisor, registered dietitian and a nurse wrote in the patient's file that he was having difficulty chewing and that he was coughing while drinking “thin liquids.” But no records exist to show that any staff member alerted the resident's doctor or tried to alter the man's diet or supervise it more closely, the state report said.

During lunch, the patient slumped over in his wheelchair after coughing repeatedly. Staff members performed CPR and performed the Heimlich maneuver on him before paramedics arrived. The patient died despite those efforts and other life-support treatment, the report said.

A woman who answered the phone yesterday at the Escondido Care Center declined to comment. The facility's owners have appealed the citation.

State records show that the nursing home had been cited in 2006 on a lesser violation for failing to grant a resident's request to keep his bedroom door open.

The staff also was accused of not responding promptly to the same patient's call light. The resident fell and broke his hip because he had to get out of bed to summon help.

State regulators fined the nursing home $1,000, and the facility's owners have appealed that penalty as well.