Nursing Home Resident Chokes to Death – Harvey Cohoon vs Victoria Healthcare and Rehabilitation

Nursing Home Resident Chokes to Death

Nursing Home Resident Chokes to Death on Chicken Prepared by In-House Cook.

Remembering Harvey Cohoon. An amazing Grandfather, Parent, Boeing Electrical Engineer, and Gentleman.

Harvey Cohoon vs Victoria Healthcare and Rehabilitation:

Harvey Cohoon was born in Michigan in 1934. After graduating high school, he attended the Detroit Institute of Technology. He became a certified technician in electronics and radio repair. In search of greater opportunity and more sunshine, Harvey moved west to Southern California.

He began working for Controlled Data Solutions. It was a supercomputer company in the 1970s that made the big mainframe supercomputers made popular before the development and commercialization of the personal computer. Harvey served as a maintenance engineer, responsible for repairing and maintaining the supercomputers used by various major corporations like Boeing and Rockwell. Harvey was hired away from CDS by Rockwell in 1981. He worked for that company before it merged with Boeing in 1996. Harvey spent the rest of his career working for Boeing until his retirement.

Harvey Cohoon’s friends and family gathered to reminisce about Harvey at Duke’s in HB, his favorite restaurant. His friends fondly recalled how when it came time for a game of Trivial Pursuit, Harvey was the most popular and fought over a teammate in the room due to his piercing and profound intellect.

Rectal Cancer and Failures of Victoria Healthcare Center:

Harvey was diagnosed with adenocarcinoma, a form of rectal cancer, on On December 3, 2012. Harvey was fortunate in that it was a low grade.

He was given a positive prognosis, and his chance of survival was estimated at 80-90% by his oncologist. He endured radiation treatment five days a week with a weekly round of chemotherapy. Cancer treatment is hard on the body. Harvey’s physical strength was reduced as he battled the disease (is it a disease) and the side effects of the treatment. As a result, he was admitted to a nursing home until he regained his strength. Harvey had every intention of returning home after completing his cancer treatment.

Harvey’s closest friend, Randy, visited Harvey several times while he resided at Victoria Healthcare Center. He visited Harvey a day or two after Christmas and recalls that Harvey was regaining his strength. Harvey commented that he felt stronger and was looking forward to leaving Victoria to return home. Randy was shocked when he was informed of his best friend’s sudden passing just a few days later.

Dysphagia: Swallowing Problems in the Elderly.

Harvey’s premature and tragic demise could have been avoided. Most members of the general public have probably never heard the term dysphagia, meaning difficulty with swallowing. It is a medical condition that mostly affects the elderly. The condition significantly increases one’s risk of choking and aspirating. Harvey was diagnosed with the condition by a Speech Therapist on the morning of December 28, 2012. As a result, his diet was changed from a regular diet to a mechanical soft (chopped) diet (dysphagia diet). A dysphagia diet will consist of foods that are easy to chew and swallow. Foods that are in large chunks or pieces or that are very hard and cannot be chewed easily are to be avoided on this type of diet. Universally accepted guidelines for a mechanical soft chopped diet require that as it relates to chicken, the individual pieces of chicken are to be chopped into individual pieces, ranging from ¼ to ½ inch in size.

Particles of chicken, described as “chunks” and “pieces” by the emergency responders, were removed from Harvey’s airway with forceps. One of the emergency responders, an EMT, was asked to draw a picture of the size of the chicken removed from Harvey’s throat. One piece was estimated at 2x the size larger than what was required by his new diet.

On December 28, 2012, Victoria served Harvey chicken, vegetables, and a baked potato for dinner. Harvey would never dine at Duke’s again; this meal would be his last.

Defendant misrepresented the true cause of Mr. Cohoon’s injuries to the emergency responders evidenced by Ms. Parr’s report to the 911 dispatcher.

Harvey was discovered in his room at Victoria around 5:40 in the evening on December 28, 2012. He didn’t have a pulse, he wasn’t breathing, and he was non-responsive. A nurse at Victoria performed CPR but was unable to get his heart beating. A recording of the call made to the 911 dispatch by a facility nurse made no mention of an obstructed airway.

Nursing Home Resident Chokes to Death – Remembering Harvey Cohoon.

Harvey Cohoon tragically passed away on December 29, 2012, after his family decided to take him off life support. His life was cut short when his airway became obstructed by multiple chunks and pieces of chicken. Unable to breathe, he experienced respiratory arrest followed by cardiac arrest. Through the heroic measures of personnel from the Costa Mesa Fire Department who were able to get Harvey’s heart beating, it was estimated that his brain had been without oxygen for 28 minutes. As a result, he suffered a devastating hypoxic brain injury. He would not be able to survive without the benefits of life support and he would never regain consciousness. Thus, Harvey’s beloved niece made the difficult decision to take him off life support.

Failure of Orange County District Office of California’s Department of Public Health

Harvey’s family filed a complaint with California’s Department of Public Health (DPH) at the Orange County district office. DPH is the governmental entity responsible for regulating nursing homes in the State of California. It was the family’s hope that what happened to Harvey at Victoria would never happen again at that facility. DPH conducted an investigation, and although the investigator substantiated the complaint’s allegations, DPH concluded that the facility had not violated any of the regulations that apply to nursing homes. Had DPH found a regulatory violation, the facility would be required to develop, adopt, and implement what is known as a “Plan of Correction”, or POC. A POC is designed to address and rectify the clinical shortcomings of a given nursing home. Because DPH found no regulatory violation against Victoria in the death of Harvey Cohoon, the facility continued to conduct business as usual. When Victoria’s Director of Dietary Services was asked following Mr. Cohoon’s death, whether she provided any educational training with the cooks or the dietary department regarding the contours and standards for a mechanical soft diet, she replied “no”.  Victoria’s failure to address the breach which caused Harvey’s death, presents a threat to the health and safety of current and future residents at the facility.

Every nursing home in the State of California is required by law to employ an Administrator. The Administrator sits at the top of the management hierarchy at the facility. The California Health & Safety Code §1416.68 obligates the Administrator to “plan, organize, direct, and control the day-to-day functions of a facility and maintain the facility’s compliance with applicable laws, rules, and regulations.” Accordingly, the Administrator must ensure that his employees are adequately trained and qualified to carry out the functions of the facility in compliance with state and federal regulations designed to protect the residents from avoidable health and safety risks. Most Administrators in the nursing home industry work full-time and are physically present at the facility to monitor its operations. Victoria’s Administrator worked full-time as an Administrator at another facility in Orange County called Palm Terrace Healthcare Center. Both Victoria and Palm Terrace are owned by a publicly-traded corporation called Ensign Group, Inc. (NASDAQ: ENSG), a for-profit nursing home chain that owns around 130 nursing homes nationwide.  The Administrator is typically the highest-paid employee of the nursing home, making between $100,000 and $200,000 per year. Victoria’s Administrator spent a few hours per week on the facility premises and was compensated $500 per month to allow Victoria to operate the facility under his license. Following Harvey’s death, Victoria’s Administrator did not do anything to ensure that what happened to Harvey would not happen again.

Harvey’s family appealed the decision by the Orange County district office all the way up to the central office in Sacramento. DPH decided to uphold the OC District Office’s decision stating that “no additional supplemental evidence was provided that would alter the findings of the investigation.” DPH made no mention of sworn deposition testimony by the ER physician at Hoag Hospital stating “The food obstructed his airway above his vocal cords. He became hypoxic or had a condition where he wasn’t exchanging oxygen for his vital organs.  He had a shutdown of his heart and then his brain…So I believe that was probably the sequence of events that ultimately led to his future demise.” DPH also ignored the testimony given under oath by the EMT who witnessed the chunks of chicken being removed from Harvey’s throat. He drew diagrams showing that the largest piece of chicken was the size of two nickels placed side by side. For a frame of reference, the pieces of chicken that Harvey was supposed to receive should have been at most the size of a dime. 

Harvey’s untimely death, as tragic as it was, presented an opportunity to improve the care received by thousands of current and future seniors resident at Victoria and the other 127 facilities owned by the Ensign Group, Inc. Had DPH cited Victoria for a regulatory violation,  Victoria would be required to develop, adopt, and implement remedial measures to ensure that residents at risk for choking due to swallowing difficulties receive the safe and appropriate food. This lack of accountability for the nursing home industry jeopardizes the health and safety of one of our society’s most vulnerable populations, the elderly. Harvey’s death was a missed opportunity by DPH to make our seniors all a little safer.

Orange County Elder Abuse Jury Verdict! $1.25 Million. ‘Choking-Chicken’ Case:

A jury in Orange County, California, awarded $1.25 million to the family of a nursing home resident who died as a result of neglect at the Victoria Healthcare & Rehabilitation Center located in Contra Costa.

In the lawsuit, the elder abuse attorneys at Moran Law alleged that Victoria Healthcare and their parent company, The Flagstone Group, Inc. were negligent in the care of a 78-year-old patient suffering from colon cancer which ultimately led to his death.

According to a press release from the elder law firm Moran Law,  Harvey Cohoon was checked into Victoria Healthcare & Rehabilitation after he was diagnosed and was undergoing radiation and chemotherapy. Shortly into his stay, Cohoon began experiencing trouble with swallowing, and the home was urged to change his diet. A speech therapist for the facility ordered his food chopped up and made it easier to chew and swallow. Staff was also instructed to monitor Cohoon while he ate to prevent him from choking.

But, sadly, the facility failed to follow those instructions, causing Coohon’s death. According to the suit, on December 28th, 2012, the same night the speech therapist changed his diet, Cohoon was served a chicken dinner that had not been cut up and he choked. Emergency crews were called to the home and made attempts to revive him, but 24 hours later he was pronounced dead due to a lack of oxygen to the brain, according to the Moran Firm press release.

Although, regulators for the California Department of Health investigated the incident and found no wrongdoing on behalf of the Victoria Center or the Flagstone Group, an Orange County jury disagreed and awarded the family a substantial settlement.

When healthcare or other professional makes a recommendation about an elderly person’s care, they and their family have a reasonable expectation that those recommendations will be followed for the health and safety of their residents. These recommendations are not arbitrary, they are very important and should never be ignored or disregarded. But, unfortunately, as the case of Harvey Cohoon demonstrates, many facilities across the state of California do not follow those recommendations with deadly consequences.

When a nursing home resident’s needs are not met it is possible for that resident or their family to pursue the facility for compensation. In the event that your loved one’s care is ignored or neglected, you are encouraged to contact a Santa Ana nursing home abuse attorney to discuss the facts of your case. They will help you determine if you have grounds to file a personal injury or wrongful death suit and will diligently work to ensure you receive an optimal settlement for your costs and emotional anguish.

Our nursing home abuse attorneys serving Santa Ana understand the pain and heartache nursing home neglect causes for thousands of families across the state.