Alden Estates Courts Of Huntley Resident Chokes To Death – Second Choking Incident In 2 Days

IDPH has cited Alden Estates Court of Huntley nursing home after a resident died due
to choking on food. Unbelievably, this was the second time this particular individual
choked on food being served to him in 2 days. While he managed to avoid serious
complications from the first choking incident, the second ultimately proved fatal.

This resident suffered from a variety of long-term conditions and had diagnoses of
dysphagia (difficulty swallowing), Parkinson’s disease, and dementia. All of these
conditions can place a nursing home resident at risk for choking.

The resident recently had his diet upgraded from a mechanical soft diet to a general
diet, but still required distant supervision while eating. The facility speech therapist
explained that “distant supervision” meant that the resident had to eat in the dining room with staff present.

On the day of the first choking incident, the resident began to choke while eating dinner. A resident called for help an aide entered the dining room and saw that the resident was choking. She saw that there was no other staff members in the dining room and did not know what to do. A nurse entered the dining room and said, “That’s not my resident, I’ll go get his nurse.” By the time that the resident’s nurse made it into the dining, the resident had coughed up the food he was choking on.

His nurse practitioner saw him that day, and entered a number of orders for an
evaluation by speech therapy and 1:1 assistance with feeding at a low rate. The nurse
did not enter the orders into the resident chart and while she told the oncoming nurse at change of shifts about the “coughing” incident, she did not tell the oncoming nurse
about the orders given by the nurse practitioner. She told the IDPH surveyor that she
was “too busy” to enter the orders into the resident chart or advise the CNA’s about the
need for 1:1 supervision.

Further, while she told the IDPH surveyor that there was not enough staff to do 1:1
feeding as ordered by the nurse practitioner, she did not tell the nurse practitioner that.
The nurse also believed that she had the ability to downgrade the diet to mechanical
soft but did not do so.

Federal regulations require that nursing homes provide supervision and assistance
necessary to prevent accidents, and a choking incident such as this is an accident in the meaning of the federal regulations. To comply with the federal regulations, nursing
homes must provide the necessary supervision to residents at risk of choking such as
this gentleman.

The following morning at breakfast, the resident began to choke again, this time on a
sausage. The nurse assigned to him heard calls for help. The nurse entered the dining
room and saw that the resident was blue and appeared lifeless. There was no other
staff in the dining room. The nurse began to do the Heimlich and was able to get some
food from the airway. The resident’s oxygen saturation levels were in the 60s, when
they should be in the high 90s, indicating significant oxygen deprivation.

911 was called and the resident was brought to the hospital where he died 10 days later due to aspiration pneumonia (likely caused by food particles entering the lungs) and complications from the choking incident.

There were a number of immediately apparent breakdowns in the care that this resident received. The most obvious is the failure to implement the orders of the nurse
practitioner to provide 1:1 supervision while eating. Past that, the oncoming nurse
should have been advised of the choking incident (not a “coughing incident”) and of the orders that had been given by the nurse practitioner. These failures led directly to the death of this resident.

While there are obvious shortcomings of the staff, it is apparent that management
choices also contributed to the death of this resident:

– The nurse told the IDPH surveyor that there was not enough staff to do 1:1
supervision while eating. Federal regulations require nursing homes to provide
enough staff to meet the care needs of residents on a 24/7 basis. Whether this
perception on the part of the nurse contributed to her decision to not enter the
orders of the nurse practitioner or communicate them to the oncoming nurse is a
question worth pursuing.

– There was no staff present in the dining room during either choking incident even though both happened during regularly scheduled mealtimes.

– The aide on duty during the first choking incident did not know how to handle a
choking resident. This speaks to a lack of investment in training the staff on the
part of facility management.

One of our core beliefs is that many of the unnecessary injuries and deaths that occur in nursing homes happen due to choices that are made in the management of the facility, and understaffing and failing to invest in training staff are a core part of the nursing home business model. Sadly, those choices can have tragic outcomes as was the case here.