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Sonora Nursing Facility Cited, Fined Due To Resident’s Death

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Sonora, CA – State health officials have issued what they describe as one of the most severe penalties under state law against a Sonora-based skilled nursing facility, due to a resident’s death by choking.

While the event in question occurred in mid-2014, the California Department of Public Health (CDPH) announced Tuesday that it issued a Class “AA” citation and $80,000 fine to Avalon Care Center located at 19929 Greenley Road.

According to Matt Strange, Avalon’s Salt Lake City-based vice president of marketing, who spoke with Clarke Broadcasting Tuesday afternoon, his company has appealed that citation and fine. “[We] are following the processes with that…and since have submitted — and had accepted — a plan of correction to the State of California, and have been found in compliance with all rules and regulations associated.”

Avalon Shares Its Side

Avalon operates a number of care communities in six states. The Sonora facility and another in San Andreas are among its nine California properties. According to Strange, well ahead of CDPH’s involvement, the incident was immediately investigated by Avalon after it occurred back in August of 2014. In fact, he notes, “We were the group that notified the State before they came into the facility…at our request.”

According to the CDPH report, the investigation centered around the care of a 90-year-old resident who had been admitted to the facility the previous year with a history of issues relating to health problems, including from inhaling food. He was under a patient order for soft meals with ground meat and extra sauce or gravy so that it could be more easily ingested. A review of the patient’s in-house care records stated as the resident was at risk for choking. Listed care goals in his chart included no choking episodes; providing a diet texture as ordered and assistance/supervision with all meals. A speech language pathologist (SLP) who worked with the resident provided a pointed, written caregiver goal: keep him from choking to death.

The CDPH investigator cites that treatment reports from the SLP indicated inconsistencies by staff, despite written instructions to provide suitable meals, supervision and direction to the patient while he ate. The investigator also indicated that facility incident reports in May and June of 2014 showed that the resident choked on cake and a dinner roll in separate incidents.

Details Behind The Death

Further into the investigator’s write-up, additional details are shared relating to the date of the resident’s death, during which the responding ambulance crew to Avalon, responding to a 911 call, found the resident unresponsive, pulseless and not breathing, and subsequently removed rice and a large piece of chicken the size of a 50-cent piece from his throat. The coroner, whose findings were consistent with the pre-hospital care statements provided by the first responders, confirmed that the resident’s death was consistent with choking on a large piece of chicken that had blocked his airway.

The resident’s last meal,  listed as a chicken quesadilla with Spanish rice and beans, appear to have failed safety standards on at least three levels, based on post-event scrutiny by the inspector. While the meal appeared to be appropriate for the patient, according to a vocational nurse on duty in charge of inspecting the tray, she identified it as “a layered enchilada,” assuming the ingredients met his dietary requirements. The dietary manager, when interviewed, maintained that the directions for preparation were for pieces of chicken to be chopped fine using a food processor.

A certified nursing assistant (CNA) who had passed out the trays in the dining room on that fateful day stated that she was the lone CNA, when there were usually at least two more CNAs on duty. After having brought the patient his tray, she left to bring a tray for his tablemate. Noticing at that point that the resident seemed in distress, she asked him if he needed the choking maneuver. When he nodded, she attempted to provide assistance.

A Perfect Storm For Disaster?

Asked if he considered the chain of events a perfect storm for a tragic disaster, Strange replies, that while the state report contains ugly information, he considers the incident “uncommon and unfortunate.”

Strange adds, “I think that it is important to note that we continue to work closely with the State of California on all regulations and any sort of care standards to make sure at the forefront of everything we do is patient care. While we really do feel that this unfortunate event is one that regrettably happened, we have been working closely with the state to make sure that it does not happen again.”

Looking at the aging population, Strange shares that his industry is continuing to see a greater need for patients requiring assistance not only with eating, but walking and getting dressed, and that Avalon is working with that trend. Simply put, he says, “What we continue to see is a greater need, as people continue to live longer — it is increasing the role of skilled nursing.”

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