Nursing Home Resident Chokes to Death

Harvey Cohoon was born in Michigan in1934. He became a certified technician in electronics and radio repair.
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Nursing Home Resident Chokes to Death on Chicken Prepared by In-House Cook. Remembering Harvey Cohoon.

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 was born in Michigan in1934. 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, a company that performed maintenance for the big mainframe super computers which dominated the computing industry before the development of the personal computer. Harvey served as a maintenance engineer, responsible for repairing and maintaining the super computers which were used at the time by major defense contractors like Boeing and Rockwell. Harvey was hired away from CDS by Rockwell in 1981. He worked for Rockwell until its aerospace and defense units merged with Boeing in 1996. Harvey spent the rest of his working days as an engineer for Boeing.

At his celebration of life, Harvey Cohoon’s friends and family gathered at Duke’s in Huntington Beach, Harvey’s favorite restaurant. His closest friends and family regaled with stories about Harvey, like when it came time for a game of Trivial Pursuit, Harvey was the most sought after teammate due to his piercing and profound intellect. Harvey’s passing, while it evened the playing field in the local Trivial Pursuit match, illustrates how far this State still has to go in caring for and protecting the elderly.

Rectal Cancer and Failures of Victoria Healthcare Center

On December 3, 2012, Harvey was diagnosed with a very treatable form of rectal cancer, called adenocarcinoma. Harvey was fortunate in that it was low grade. He was given a positive prognosis. His chance of survival was estimated at around 90% by his oncologist. Harvey was to undergo radiation and chemotherapy treatment. While undergoing his treatment, Harvey was admitted to a nursing home in Costa Mesa called Victoria Healthcare Center. He was to remain there during the course of his treatment until he regained his physical strength. Harvey had every intention of returning to his home in Fountain Valley.

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, and should have, been avoided. Most people have probably never heard the term dysphagia, meaning difficulty with swallowing. Dysphagia mostly affects the elderly. It increases one’s risk of choking and aspirating. Harvey was diagnosed with dysphagia by a Speech Therapist on the morning of December 28, 2012.

Harvey’s swallowing problems were described as “severe” and his ability to protect his airway was “severely” compromised. As a result, his diet was changed from a regular diet to a dysphagia diet, called “mechanical soft chopped”. A dysphagia diet will consist of foods that are easy to chew and swallow. Foods that are served 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 dysphagia diet require that, as it relates to chicken, the individual pieces are to be no larger than ¼ to ½ inch in size. 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.

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 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, at Hoag Hospital. His life was cut short when his airway became blocked with multiple chunks of chicken. Chicken described as “chunks” 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 more than twice the size than what was required by his new diet. A physician at Hoag Hospital removed another 10 pieces of chicken from Harvey’s airway in the emergency room.

Harvey’s obstructed airway induced respiratory failure followed by cardiac arrest. Through the heroic measures of the emergency responders with Costa Mesa Fire Department, an airway was established after the paramedics removed chunks of chicken that were blocking Harvey’s airway. The paramedics were able to get Harvey’s heart beating again, but it was too late. It was estimated that Harvey’s brain had been without oxygen for 28 minutes. As a result, he suffered a devastating hypoxic brain injury. A man of famed Trivial Pursuit dominance had been reduced to a vegetable. He would never regain consciousness, so his 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 the Orange County District Office of California’s Department of Public Health. DPH is the governmental entity responsible for regulating nursing homes in the State of California. Harvey’s family hoped to prevent another tragedy like Harvey’s by filing a complaint with DPH. An investigation was performed, 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. In fact, a facility nurse testified under oath that the investigator informed him that Victoria’s nursing staff had done everything correctly, and commended the staff for its conduct.

Had DPH found a regulatory violation, the facility would have been required to develop, adopt, and implement what is known as a “Plan of Correction”, or POC. A POC is designed to address and rectify clinical a shortcoming in a nursing home which threatens the health and safety of its residents. Because DPH found no regulatory violation against Victoria for the death of Harvey Cohoon, the facility continued to conduct business as usual. When Victoria’s Director of Dietary Services was asked under oath whether Harvey’s death prompted her to provide training to the cooks or the dietary department regarding the contours and standards for a mechanical soft diet, she replied, “no”.  The cook who prepared Harvey’s fatal meal also testified under oath that he had not spoken to anyone at the facility about what happened to Harvey. Victoria’s failure to address the improper meal served to Harvey which caused his death, threatens the health and safety of Victoria’s current and future residents at the facility. Victoria’s Director of Nursing held a meeting with the staff and concluded that nothing had been done wrong, despite testifying under oath that she personally does not know how big the individual pieces of chicken should be for a mechanical soft dysphagia diet.

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 a 130 nursing homes nation-wide.  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 OC District Office’s decision all the way up to the DPH 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 Harvey’s airway above his vocal chords. 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 roughly the size of two nickels placed side by side. The standards required Harvey’s diet dictate that the individual pieces of chopped chicken should be no larger than the size of a single 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.