IDPH has cited and fined Sandwich Rehab & HCC when a resident experienced a life-threatening choking episode due to the facility’s failure to provide an appropriate diet.
The resident in question was admitted with various diagnoses including oropharyngeal phase dysphagia, which affects swallowing.
After a speech therapy session a physician ordered a diet downgrade to “Mechanical Soft/Chopped Textures TL (thin liquid).”
However, this order was not properly implemented.
Approximately three weeks after the new diet was ordered, the resident choked while eating an Italian beef sandwich in the dining room.
A nursing note from that day states, “Resident began to have signs and symptoms of choking. A CNA did the Heimlich, as the resident was sitting in his chair. I approached, resident not responding, color poor, we laid him on the floor, CNA did abdominal thrusts, turned him on his side, still choking, did another set of abdominal thrusts, turned him on his side, object/food expelled resident breathing, alert…”
A Registered Nurse later reported, “His diet was regular at the time. It is mechanical soft now. He had a regular tray…” This statement reveals that the resident was not receiving the prescribed diet at the time of the incident.
The facility’s failure to implement the ordered diet change was attributed to communication breakdowns and inadequate processes. The Dietary Manager stated, “the nurse is supposed to send diet changes to the kitchen in paper form. They do not make changes until the order comes from the nurse and that is when the dietary card would be changed.”
Even after the choking incident, proper precautions were not consistently followed. Approximately five weeks after the choking incident the resident was observed being served a grilled ham and cheese sandwich that was not mechanically altered, contrary to his dietary needs.
The Director of Nursing acknowledged the systemic issues, stating, “I don’t know where the breakdown happened. I don’t know if the dietary card did not get changed or they just didn’t read it.”
The facility’s policies outline clear procedures for managing diet orders and assessments. However, these policies were not effectively implemented in the resident’s case. For example, the policy states, “The Food Service Manager or designee re-evaluates and documents each resident’s nutritional problems or needs at least quarterly.” Yet, the resident’s most recent quarterly dietary assessment was completed approximately 8 months prior to the incident.
All of this highlights the critical importance of proper communication, documentation, and implementation of dietary orders in healthcare facilities, especially for residents with swallowing difficulties.
One of our core beliefs is that nursing homes are built to fail due to the business model they follow and that unnecessary accidental injuries and wrongful deaths of nursing home residents are the inevitable result. Our experienced Chicago nursing home lawyers are ready to help you understand what happened, why, and what your rights are. Contact us to get the help you need.
