The California Department of Public Health cited a North Hollywood nursing home after investigators found that staff mistakes caused a resident to choke -- and eventually die -- after being given medication mixed into applesauce.
Windsor Gardens Healthcare Center of the Valley received a $75,000 fine and a Class AA citation, “the most severe penalty under state law,” according to a news release from the Department of Public Health.
The partially redacted summary of deficiencies released by the department identified the resident only as a female who died sometime in 2013.
“The facility’s licensed nursing staff failed to ensure that Resident 1, who was assessed as having difficulties in swallowing, was not given oral medication mixed in applesauce. This violation resulted in the resident choking on the medications in applesauce, her oxygen levels decreased, the paramedics were called and upon arrival they had to intubate the resident,” the summary said.
“Resident 1 was transferred to [a hospital] ... where she expired two days later as a result of aspiration pneumonia. The above violation presented either imminent danger that death or serious harm would result, or a substantial probability that death or serious harm would result, and was a direct proximate cause of the death of Resident 1.”
News of the fine comes hours after the state released an audit that found that the California Department of Public Health had failed to effectively investigate nursing home complaints, with a total of 11,000 unresolved complaints in its system.
Agency spokesman Corey Egel said the timing of the release had “nothing to do” with the state audit.
“This news release has been in the works for a few days prior to the report released yesterday, the timing of which is simply coincidence,” he said.
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