Newport Nursing and Rehabilitation
Center in Newport Beach and Emeritus at Yorba Linda received Class
“AA” citations, the most severe penalty under state law, for inadequate care that
led to a death at each nursing home this year. After California Department of Public Health (CDPH) investigations into each facility, Newport Nursing and Rehabilitation Center was fined $100,000 and Emeritus at Yorba Linda received a $90,000 fine.
Newport Nursing and Rehabilitation Center, 1555 Superior Ave., was dinged for failing to provide adequate safety measures and supervision that led to the patient's death, state public health officer Dr. Ron Chapman announced today.
According to the CDPH citation, a woman who was convalescing at Newport Nursing and Rehabilitation Center after falling and breaking her hip at home was found in the bathroom of her room face down, unresponsive and with no pulse just before 11 a.m. on Sept. 6. Not breathing and having no heart beat, the woman was rushed to the emergency department, where she was pronounced dead shortly after 3 p.m.
Because the woman had a history of falling, including the one that broke the bone that put her in the recovery facility, it was required that two staff members always help her on and off the toilet and assist her cleaning up. This requirement was noted dozens of times in the facility's own patient log for her leading up to that fateful day. The records also mentioned the woman had been slipping deeper into dementia the longer she was at the center.
On the day the woman died, records show only one nurse helped the woman to the bathroom door, which was shut behind her when she requested privacy. The nurse then called out for a second staffer to watch the woman and left for lunch. That second person never arrived. A maintenance worker who came into the patient's room while doing light inspections saw neither her nor the nurse, opened the bathroom door and found the unresponsive woman.
The nurse who had accompanied the woman to the bathroom door no longer works at Newport Nursing and Rehabilitation Center. But the CDPH did not let the facility off the hook. The citation orders the nursing home to identify all remaining patients who have a risk of falling (in other words, just about all of them). Care plans must be devised for each one, noting the potential risks and ways to avoid them. All falls must be reported to other staff at daily briefings and audited on a regular basis by supervisors who can then implement further care.
The CDPH cited no problems with the life-saving efforts undertaken at the facility after the woman was discovered with mortal head wounds. Her family made the gut-wrenching decision to take her off a ventilator before she passed away.
Chapman disclosed today that Emeritus, 17803 Imperial Highway, failed to serve a diet as prescribed resulting in a patient choking and then dying. A female patient in the facility's care was supposed to be served soft food only, including meats that were either ground or chopped. But on June 1, she was served a ham sandwich for lunch.
“. . . Patient A was found unattended, unresponsive and cyanotic (blue color from lack of oxygen), with a partially eaten sandwich in front of her,” reads the CDPH citation. “The Heimlich maneuver (an emergency technique used to prevent suffocation when a person is choking) was performed and was unsuccessful. Patient A was transferred to the acute hospital, where a large piece of meat was removed from her airway. Patient A was admitted to the intensive care unit, where she remained unconscious and died six days later from cardiac and respiratory arrest due to foreign body aspiration (choking).”
Besides serving her meat that had not been ground or chopped as previously specified by the woman's physician, Emeritus staff failed to properly monitor her while she ate, the CDPH probe found.
To prevent a similar tragedy, the state agency has identified other patients with special dietary needs. The state has ordered: special training of nurses and other staff to monitor the food intake of patients requiring them; daily food audits by the director of nursing (or that official's designee); and bi-weekly visual audits by nurses.
A quality assurance committee at Emeritus will regularly review these measures. Meanwhile, the nursing home must also alert receiving facilities of the special dietary needs of patients who transfer to them.