The Illinois Department of Health has cited Spring Creek Nursing & Rehab, located in Joliet, after a resident died after choking on a meal of chicken tenders that did not meet their prescribed diet from their physician. The nurse at the community stated she changed the diet order but could not remember getting an order for the change from a physician or speech therapist.
There are many challenges that can come with aging and with conditions that arise for older adults. Swallowing, for example, can become more difficult and lead to dangerous consequences, like choking. Physicians work with speech therapists to find food consistencies that are easier to swallow for older adults who might not be able to chew and swallow plated foods.
There are two very common types of diet consistencies for those who have difficulties swallowing safely, pureed and mechanical soft. In the case at Spring Creek, the resident was on a pureed diet after returning from a hospital stay, meaning that all food on the plate was to be pureed so that it was easier to swallow.
According to the citation report, the resident had a physician order to eat a pureed consistency general diet on March 23, 2023. On April 7, 2023, the nurse at the community stopped the pureed diet simply documenting the reason for the change as “wrong diet.” There is no documentation from the physician ordering the modification or of a speech therapy evaluation to change the diet.
It is a general protocol for speech therapy to be involved with any diet consistency changes. Best practices state that to upgrade from a pureed diet, the diet should change to mechanical soft consistency before returning to a regular consistency diet. A speech therapist would observe the person changing consistency while eating and then after eating for more than one meal to ensure the older adult was safe to make the change official.
This did not happen at Spring Creek, and the consequences were dire. Once a nurse noticed a problem, the resident was wheeled outside of the dining hall. At that point the nurse did not hear an exchange of air and the resident started to make the universal sign for choking. The nurse then took a spoon to do a sweep of the resident’s mouth only to find large chunks of chicken tenders. At that point the nurse started to compress the resident’s abdomen from the front, and food started to come out of the resident’s mouth. The nurse began to hear an exchange of air, but the resident’s eyes closed and the pulse went from thready to none. The resident was rushed to the hospital and later died due to complications from an obstructed airway.
Unfortunately, there are a lot of questions here about how this happened, and why. Investigators spoke with multiple staff at the Spring Creek community, as well as the speech therapist and the physician who served the resident. The nurse who changed the order did not recall who she got the order from for the new diet. She just stated that she upgraded the diet to regular consistency because the resident was on the “wrong diet.”
This is a scary situation because of the forgetfulness of the nurse and the decision to upgrade a diet without following industry best practices. Senior living communities are busy places, but there is a process in place for upgrading diet orders. Unfortunately this process was not followed at Spring Creek and the resident paid the ultimate price for the mistake.
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. Order our FREE report, Built to Fail, to learn more about why. 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.
Other blog posts of interest:
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Piatt County Nursing Home resident breaks neck in fall from power recliner
Champaign Urbana Nursing & Rehab resident admitted to ICU with untreated urinary tract infection
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