Bakersfield Memorial Hospital has been fined $75,000 after a state investigation determined nurses failed to provide adequate supervision to a patient who choked to death last March, according to a California Department of Public Health investigation.
The administrative penalty is the third Bakersfield Memorial has received since 2009, CDPH records show. The hospital, which operates under the umbrella of Dignity Health, was cited in 2014 for not following established policies and procedures for patient monitoring and intervention, and again in 2009 for not having properly functioning anesthesia equipment.
“The care and safety of our patients and staff are the highest priority at Dignity Health Memorial Hospital and we take this matter very seriously,” Bakersfield Memorial officials said in an emailed statement. “After self-reporting this event to the California Department of Public Health, we fully cooperated during their investigation and immediately took steps to ensure the event never happens again, including developing new policy, revising processes and protocols, and providing extensive multidisciplinary staff and physician education. Consistent with patient privacy laws and hospital policy, we respect our patients’ privacy by not discussing the specifics of their care.”
The most recent incident involved a patient admitted for brain surgery who died during recovery. She was ordered to have a regular diet, but a physician required supervision during meals, the report states.
“The hospital failed to supervise [the patient] during a meal as ordered by the physician. [The patient] then died after choking on food which blocked the airway,” the report states.
The risk was documented on at least four separate occasions, the report shows.
An occupational therapist made note five days before the patient died that she “was shoveling food into her mouth so quickly that she started choking.”
Later, a registered nurse documented that she “continues to eat without chewing well and tends to choke.”
A few days after that, another nurse noted that the patient “puts more food in her mouth than what she was able to chew and swallow.”
A physical therapist who worked with the patient noticed the behavior and relayed her concerns to the licensed nursing staff and placed a note for the doctor to be aware, according to interviews public health investigators conducted.
Despite all warning signs, a nurse walked into the patient’s room on March 12 around dinner time and found her “foaming at the mouth and turning blue,” according to the report. Pieces of lettuce were scattered across her chest and “there was food all over,” the report states.
Earlier that day, the patient was choking on her lunch, and another nurse pulled a piece of lettuce from her throat, the report states.
“This facility failed to prevent the deficiency … that caused, or is likely to cause, serious injury or death of the patient, and therefore constitutes an immediate jeopardy,” the report concludes.
Bakersfield Memorial Hospital was the only Kern County hospital to be fined and is one of 17 penalized statewide.