IDPH has cited and fined Countryview Care Center – Macomb when the facility failed to ensure a resident was served the correct, Physician ordered, mechanically altered diet. This failure resulted in the resident receiving the wrong texture of diet causing him to choke on his food and subsequently requiring back thrusts, the Heimlich maneuver and transfer to the local area hospital. This failure also put the resident at
risk for death and/or brain damage from lack of oxygen due to choking.
The resident in question was on a physician-ordered “Controlled Carbohydrate Diet, mechanical soft, thin liquids, ground up meat with gravy on all meats.”
On the day of the incident a Dietary Aide admitted to serving the resident “a pork fritter type piece of meat” that was neither ground nor served with gravy. When questioned about this, the Dietary Aide stated, “I did not grind it or put any gravy on it. When a CNA requested gravy and chopped meat I cut up the meat with a knife and told her to use some other condiment on it to soften it up because I did not have any gravy.”
The Dietary Aide also revealed a lack of proper training, saying, “I have not been trained on any of this, I am doing the best I can. I was in the kitchen by myself, so a housekeeper and a CNA came in to help sling trays.”
This statement highlights significant gaps in the facility’s dietary management and staff training.
The situation was exacerbated by understaffing and poor supervision. A CNA reported, “All of us (Staff) were busy and not paying attention, when I happened to look over, he was putting a piece of meat in his mouth. He immediately began choking.” The CNA also noted that the resident usually required supervision while eating, but due to the hectic environment, proper supervision was not provided.
The choking incident required immediate intervention. A Licensed Practical Nurse stated, “When he was choking, I smacked him on the back several times and then positioned him to do the [Heimlich maneuver] and he coughed up about 120 ccs (Cubic Centimeters) of chewed up meat.” The resident was subsequently transferred to a local hospital for evaluation.
This case highlights the critical importance of proper dietary management, staff training, and resident supervision in healthcare facilities, especially for residents with cognitive impairments and special dietary needs. The incident also underscores the potential severe consequences of failing to follow physician-ordered diets and the need for robust systems to prevent such errors.
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