San Diego Care Center Cited for Patient’s Choking Death

The California Department of Public Health (CDPH) cited the San Diego care facility Villa Rancho Bernardo Care Center (Center) for inadequate elder care, which resulted in the death of one of its residents. According to a story from NBC San Diego, the Center received the most severe penalty under state law, a “AA” citation that is accompanied by a $100,000 fine from the State of California. This isn’t the first time the Center has been cited by the CDPH. In fact, a previous citation occurred only a few years ago. Is this care center safe for patients?

What Led to the Recent Citation?
The Center had specific physician’s orders for a 61-year-old dementia patient’s diet. The patient had been admitted to the facility with a diagnosis of dementia, and his physician’s orders later stated that he had cognitive/behavior impairment (or decreased mental status).

As a result of his diagnosis, the patient required a “special chopped diet” that entailed having his food cut into very small pieces every day. According to a healthcare services manual, a “mechanical chopped diet” such as this one requires that meats be chopped “to the consistency of small dice,” or approximately ½ inch. This special diet had been prescribed because the patient had exhibited past behaviors in which he’d grab food and immediately stuff it into his mouth.

On October 31, 2012, the staff at the Center failed to have the patient’s food chopped, and the patient was served two pancakes and two uncut sausages. The patient proceeded to put all four of these food items into his mouth, and he then choked and died. The CDPH report described the Center’s negligence as the “direct proximate cause of the death of the patient.”
How Did This Happen?
According to the report, a series of people failed to notice the dietary error including: the cook, the dietary line checker, the licensed nurse, and the certified nursing assistant. None of these staff members verified “that the prescribed diet, in the correct consistency, was checked prior to bringing the meal tray into [the patient’s] room.”

The incident violated the Center’s policy on “Choking Prevention,” which states that, prior to serving meal trays to its residents, the licensed nurse assigned to the dining room is required to check that each meal matches the “diet slip” provided by each resident’s physician. Then, the Certified Nursing Assistant (CNA) is required to “double check” the tray after the licensed nurse checks it. The CNA does this in order to check “for any missed items or wrong diet” that the licensed nurse may have overlooked.

While the report doesn’t indicate how the licensed nurse and the CNA both failed to identify the problem with the resident’s meal, the CDPH is holding the Center accountable. And this isn’t the only case in which the Center has failed to provide adequate care.

History of “AA” Citations at the Center

In February 2010, less than three years before the choking death of the patient discussed above, the Center received another “AA” citation and $100,000 fine for the death of another dementia patient, who also suffered from psychosis. According to that report, the resident “sustained fatal head injuries after falling down a concrete stairwell” outside the Center. The resident, who was confined to a wheelchair, opened an emergency door and “fell down 20 concrete steps” while he was “still restrained in his wheelchair.” At the time of the fall, he was completely unsupervised. He died two days later from the injuries he sustained during the fall.

If you have an elderly loved one who has sustained injuries due to nursing home neglect, an experienced attorney can discuss your case with you. Contact us today.

See Related Blog Posts:
Glendale Nursing Home Criminally Indicated After Patient Death
Elder Abuse Investigations: Coming Soon to a Care Center Near You