IDPH has cited and fined Aperion Care West Chicago when the facility failed to ensure that a resident was adequately supervised while eating. This failure resulted in the choking death of the resident.
The resident in question had multiple serious diagnoses. Her MDS showed that she was rarely/never understood, had severe cognitive impairment, and required substantial assistance with most ADLs.
A Speech Therapist had provided recommendations for the resident which included “Continue meals in the dining room; cue as needed for safe PO (oral) intake (of food). Slower pace of PO (oral) intake (of food), upright and alert, smaller bites and single bites, smaller sips, and alternate solids and liquids.”
The facility, however, did not have documentation to show that care plan interventions for safe swallowing strategies were put in place following the recommendations of the Speech Therapist.
Around 12:30 PM, a Behavioral Aide (BA) delivered a lunch tray to the resident in her room and left her unattended. The BA stated, “I went in and set the tray down on her bed around 12:30 PM, and went out and passed other meal trays to residents. From 1:00 PM to 1:30 PM, I was outside supervising other residents for their smoking break. I did not go back to check on the resident.”
At approximately 1:20 PM, a Certified Nursing Assistant (CNA) found the resident unresponsive in her room. The CNA said, “I found the resident unresponsive, lying across her bed, with her feet still on the floor. I called for help right away. We did the Heimlich maneuver. No food came out. I could see pieces of food in her mouth.” Staff initiated CPR and called a code blue.
EMS personnel arrived at the facility approximately 15 minutes later and found the resident in cardiac arrest. Despite attempts to clear the resident’s airway, EMS personnel were unsuccessful due to the presence of food obstructing the airway. A surgical cricothyrotomy was performed, but the resident did not have a return of spontaneous circulation.
The resident was transported to the local hospital, where she was pronounced dead. The State of Illinois Certificate of Death Worksheet showed that the resident’s cause of death was asphyxia due to aspiration of a food mass.
The Speech Therapist later stated, “the resident was impulsive with eating. She needed supervision because she was impulsive. She also liked to stand up and try to walk while she was eating. Supervision means that someone is around in case something happens. She should not have eaten alone in her room with the door closed because she was at risk for choking.”
The facility failed to ensure that the resident, who required supervision and safe swallowing strategies while eating, was provided with the necessary supervision.
A simple breakdown in care leading to a horrific outcome – and the fact that no one took time to realize that this resident’s rather obvious risk of choking was not being properly addressed is a result of the fact that nurses in a nursing home setting often are stretched so thin by the grind of providing day-to-day care that they do not have time to give critical thought to the needs of resident’s. Sadly, that is directly related to the nursing home business model.
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.
