Tustin Care Center, located in Orange County, California, was fined $50,000 by the California Department of Public Health for the choking death of one resident in March 2009. The California Department of Public Health concluded that the facility’s failure to assess the resident’s ability to eat was a direct cause of his death.
According to the government’s Medicare website, the Tustin Care Center received four out of five stars, which is an above average rating. In the past year, the nursing home had nine health deficiencies, which is three less than the average health deficiencies in California, and one more than the average number of health deficiencies in the United States.
The inspection report noted that one resident choked to death after eating lunch provided by the nursing home facility. In this case, the facility failed to conduct continuing assessments of the resident. Nursing homes are required to identify problems and develop an individual care plan for all residents based on initial and continuing assessments of resident needs. This requirement is in place to provide the best and most complete care and treatment to maintain the health and well-being of residents.
The resident was admitted to the facility on October 27, 2008 with hypertension, a lung mass, heart disease, and high cholesterol. The nurse’s assessment showed that the resident had both upper and lower dentures and was alert and able to feel himself. An individualized care plan was established, part of which was to monitor the patient’s diet tolerance.
Over the course of the resident’s stay at the facility, the nursing home staff noted that the resident was getting weaker and having difficulty moving around. However, there was no mention of an assessment by dietary or by the Interdisciplinary Team (IDT) of the resident’s swallowing ability or ability to tolerate a regular diet. The IDT notes from March 2, 2009 show that the resident had a change in condition caused by a decline in activities of daily living and a decline in mobility due to a five pound weight gain within a month. Still, the nursing home staff allowed the resident to eat regular meals on his own.
On March 14, 2009, the resident was served lunch in the dining room at noon. The resident ate twenty-percent of his lunch (Korean soup with rice). At 12:30 pm, the resident had difficulty breathing, and a licensed nurse performed the Heimlich maneuver but was unable to dislodge the food. The resident was then placed on the floor and given CPR before being transferred to the hospital. The resident did not have a pulse and did not regain consciousness. The hospital report indicated that the resident arrived at the emergency room in full arrest – he was flaccid and pale with a partially obstructed airway and no heartbeat. The hospital was unable to resuscitate the resident. The autopsy confirmed that the cause of death was asphyxia due to choking on food.
This unfortunate death could have been prevented had the facility taken better care to provide ongoing assessments of the resident’s ability to eat on his own.
Click on the links for information on nursing homes in San Diego , Los Angeles and San Francisco
Medicare – Tustin Care Center
California Department of Health: Nursing Home Citations – Tustin Care Center