nursing home choking accident Archives - The Law Offices of Barry G. Doyle, P.C.

Heartland of Moline resident develops pneumonia due to failure to follow diet orders

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Second fatal choking accident at Aperion of Spring Valley in two years

December 12, 2022 By Barry G. Doyle

IDPH has cited Aperion of Spring Valley Nursing Home after a resident there choked to death while eating. Sadly this was the second fatal choking accident at that nursing home in the last two years.

In the earlier choking incident, the resident was given food which was not consistent with her dietary restrictions. She was not being supervised while eating, even those this was called for in her care plan because she was not able to eat safely due to her dementia and diagnosed dysphagia, or difficulty with swallowing. Sadly, the nursing home failed to learn or apply some of the lessons that should have been learned from this earlier fatality.

The resident involved in this incident had a number of diagnoses that would have placed him at risk of choking. First, he suffered from dysphagia, or difficulty in swallowing. He also suffered from dementia, intellectual disability, postural kyphosis (hunching of the back). When someone has diagnoses which place them at risk for choking, they are customarily referred to speech therapy, who evaluates the resident’s risk of choking and makes diet and other recommendations intended to minimize the risk of choking.

Here, the resident was in fact seen by speech therapy who determined that the resident was at risk for choking and was given a diet of mechanical soft foods with nectar thickened liquids. The recommendations also included one for constant supervision. This was backed up by physician order which in addition to the diet restrictions, also called for giving no more than a ounce of fluid at one time due to impulsivity, take small bites of food and small sips of liquid due to dysphagia, have the resident drink liquids after 2-3 bites of food.

The care planning process is a multi-step process by which risks to the health and well-being of the resident are addressed. These steps include: (1) assessing the risks to the health and well-being of the resident, (2) developing a care plan which reduces to writing the steps which must be taken to address those risks, (3) communicating the care plan to the staff members charged with carrying it out, (4) actually implementing the care plan, (5) evaluating the effectiveness of the care plan, and (6) revising the care plan if it proves to be ineffective in practice or the care needs of the resident change.

When a speech therapist issues recommendations for safe eating or a physician issues standing orders regarding diet, these are customarily included in the resident care plan. However, these were not included in the care plan for this resident.

Why? The director of nursing told the state surveyor who investigated this incident that she did not know that diets should be included in the care plan. As a result, the steps which should have been taken to keep this resident safe were not communicated to the staff.

Despite this, the staff was aware of the need for supervising the resident. They were aware that the resident would try to eat too quickly and shove more food into his mouth than was safe (something that is fairly common among nursing home residents suffering from dementia). They knew that he needed cueing to slow down and to drink water and that at times he would need assistance with the eating. They also knew that he should not be left unattended his meal tray.

On the day of this fatal nursing home choking accident, the resident was brought to lunch and seated at a feeder table with aide. The residents were being feed ground beef stew, biscuits, soft cooked vegetables, cake, and a beverage. These are items which are consistent with the mechanical soft diet.

While the residents were being lunch, the aide at the table was called out of the dining room to deal with a crisis with another resident. When she left the dining room, the tray with the food was left with the resident. There was no one supervising the resident.

Less then 5 minutes later, a family member of another resident saw that the resident was choking and yelled out that this was happening. Other staff responded and pulled the resident away from the dining room in his wheelchair. Staff at first attempted to perform the Heimlich maneuver with the resident still in the chair, but this was unsuccessful, so the resident was removed from the chair and placed on the floor. A nurse attempted to clear the resident’s airway with a finger sweep, but was only able to remove a small potion of the biscuit.

The crash cart was brought to the resident, but where he was placed on the floor was far enough away from an outlet that the suctioning device could not be plugged in, so maintenance had to be called to bring an extension cord.

In the interim, 911 had been called, and the paramedics arrived. When they arrived, the staff was still trying to clear the airway. They used a suction device and forceps and were able to remove more biscuit from the resident’s airway. However, by the time that the resident’s airway was cleared the resident had lost his pulse. There was a DNR in place, so the paramedics inquired of the hospital whether they should continue resuscitative efforts. They were instructed to continue to do compressions and bring the resident to the emergency room. However, once they arrived, the staff there determined that the resident could not be treated in a manner consistent with the DNR, so efforts were stopped and the resident was pronounced dead.

During its investigation, IDPH determined that only one nurse was in the building who had a current CPR certification, and she was not involved in the care of this resident because she was assigned to work the COVID wing of the building. The aides involved were not certified, either. This was despite a facility-wide policy requiring all staff to have current CPR certifications. The director of nursing explained to the state surveyor that there had been changes in the human resources department and the certifications were not being tracked.

The key issue here is that the resident was not being supervised while eating despite a well-recognized need for doing so. The resident was left unattended with his meal tray while the aide left to help elsewhere. While this was going on the resident ate too much biscuit too quickly (a behavior which was well-known to the staff) which he was not able to swallow because of his dysphagia. The aide simply should not have left him unattended and with his meal tray. If helping with the other resident was absolutely necessary, then the tray should have been taken out of the reach of the resident. Instead, he was left unattended to the point that it fell to a visiting family to recognize that the resident was choking.

After one previous fatal choking accident, the nursing home should have learned a hard lesson about failing to supervise residents who were at risk of choking, but that lesson was not absorbed. Sadly, failing to learn hard lessons seems to be too often true in the long-term care industry. 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:

Fondulac Rehab resident chokes to death

Heartland of Moline resident develops pneumonia due to failure to follow diet orders

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Chicago Ridge Nursing & Rehab resident chokes to death

January 14, 2022 By Barry G. Doyle

IDPH has cited and fined Chicago Ridge Nursing & Rehab nursing home after a resident there choked to death on a sandwich.

When a resident is at risk for choking, this should be addressed in the care planning process. This may include having a swallow evaluation done by a speech therapist to come up with modified diet orders or other approaches to eating which can serve to reduce the risk of choking. The recommendations of the speech therapist should be incorporated into physician orders and/or the resident care plan, which then must be carried out on a day-to-day, shift-to-shift basis.

One of the kinds of records that are unique to the nursing home industry is the Minimum Data Set, or MDS. The MDS collects information regarding the resident’s condition, care needs, and the levels of assistance needed. The MDS forms part of the basis by which the reimbursement (or payment) levels for the nursing home are set, so there is a requirement that the MDS be completed under oath. Because the MDS is certifying that the resident needs and is receiving a given level of care, the care shown on the MDS is usually incorporated into the resident care plan.

The resident at issue had a number of medical issues, including suffering from dementia and having had a history of stroke. There was a physician order in place for a puree diet. The resident had a series of know n behaviors, including frequently goin into other resident’s rooms and stealing food from other residents. Her care plan included one person assistance and supervision while eating and supervision related to her dementia. The staff interviewed after this choking incident however told the state surveyor that she was able to eat without supervision and was alert and oriented to person, time, and place.

Her Minimum Date Set (MDS), however, told a different story. It described her as having severe cognitive impairments. With regard to eating, it stated that she required supervision of one while eating, that she experienced loss of food or liquid from the mouth while eating, and that she showed signs of a swallowing disorder in the form of pocketing while eating. This is very clearly the picture of a resident who was at risk for choking and required supervision. This is also consistent with the care plan.

On the day of this nursing home choking accident, the resident was found unresponsive in bed with a piece sandwich in her mouth. She was not breathing. Paramedics were called, but since she was a DNR, they did not attempt to resuscitate her and did not bring her to the hospital. Case of death per the death certificate was asphyxia due to choking on a food bolus.

There were a number of shortcomings in the care that this resident received which led to her death:

The staff was not aware of what the care plan called for – they believed that the she was capable of eating independently when she required supervision due to her swallow difficulties and cognitive impairments. Communicating the contents of the care plan to the staff charged with carrying it out is a basic part of the delivery of care via the care planning process;
The care plan did not address her known behavior of taking food from other residents. The physician’s order called for a puree diet and consumption of anything that was not pureed would be a violation of that order. As part of the care planning process, the care plan must be revised when it prove inadequate in practice. If the resident was taking food from other residents which placed her at risk for choking, this is a risk to the health and well-being of the resident which must be addressed in the care plan. Sadly, it was not.
The care plan called for supervision of the resident, but we know that leading up to the choking incident, she obtained a sandwich from somewhere, began to eat it, and choked on it – all without the knowledge of the staff. As noted above, the staff should have been monitoring this resident specifically for the taking of food which she was not supposed to have, but that was not being done – and it also appears that the more general supervision was lacking as well.

Together, all of these failures led to the very preventable death of this resident. 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:

Winston Manor resident chokes on peanut butter sandwich

Bella Terra Wheeling resident chokes to death

Alden Poplar Creek resident chokes to death

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Sunset Rehab resident chokes to death

September 1, 2021 By Barry G. Doyle

IDPH has cited and fined Sunset Rehabilitation & Health Care nursing home in Canton after a resident there choked to death while eating lunch.

The resident at issue here had a history of having had a traumatic brain injury. One way in which this manifested itself was in behavior disturbances which manifested itself by eating very rapidly, not chewing, and walking around while eating. These behaviors placed the resident at risk for choking.

When a resident is at risk for harm, it is incumbent on the nursing staff to develop a care plan outlines a series of steps which are to be taken on a day-to-day, shift-to-shift basis to prevent the harm from occurring. It also recommended that he be given “finger foods” to eat. In this case, the steps incorporated into the resident care plan was to provide one person assistance with eating – a level of care which was also documented on the resident’s Minimum Data Set (MDS).

On the day of this nursing home choking accident, the resident was given a slice of ham, sweet potatoes, and a vegetable to eat. He got up from the table while still eating and began to choke, collapsing in a nearby hallway. The staff attempted to clear the airway and perform CPR, but the resident died before he could be brought to the hospital. Cause of death was brain hypoxia, or loss of oxygen to the brain.

IDPH’s investigation of the incident uncovered a number of troubling findings:

Even though the use of finger foods was a part of the resident’s care to address his risk of choking, there was no diet order to that effect. In fact on the day that he died, he was served ham and sweet potatoes – things that can hardly be characterized as finger foods. Further the ham was not cut into smaller pieces to mitigate the risk of choking. The facility cook stated that he was not aware of the resident’s care plan and never looked at resident care plans.
The resident’s care plan called for one person assistance with eating while he was only receiving supervision that day. The difference between the two is getting some physical help versus cues and reminders to slow down while eating. The net difference here was that there was no one to cut his food into smaller pieces which very easily could have been the difference between having a fatal choking accident and surviving this event.
Many of the staff had expired CRP certifications, including several of the staff members who responded to the emergency. Beyond having expired certifications, the ambu-bag (a device which uses a bag to force air into the lungs during CPR) was never employed until the paramedics arrived, the staff did not know how to determine the resident’s code status, or whether CPR should be attempted on a resident who is DNR (it should).

This is a classic example of a situation where the nursing has failed the resident for a long period of time, but avoided catastrophe only by sheer luck. Good luck is not a substitute for good care. The resident had a care plan which did not correlate with the diet orders, the process by which that care plan would be implemented (having the kitchen prepare meals which complied with the car plan) didn’t work because the kitchen staff didn’t review care plans, and the staff was ill-trained and without required certifications. This is an accident which could have occurred to any number of residents on any number of days.

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:

Resident at Aspen Rehab in Silvis chokes to death due to failure to follow care plan

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Resident at Aspen Rehab in Silvis chokes to death due to violation of care plan

August 6, 2021 By Barry G. Doyle

IDPH has cited and fined Aspen Rehabilitation & Health Care nursing home in Silvis after a resident there choked to death on a sandwich due to a violation of the resident care plan.

The resident involved in this nursing home choking accident was a long-term resident of the nursing home. He suffered from schizophrenia, anxiety, and dementia. Some people afflicted with this set of conditions tend to eat very quickly, shoving food into their mouth and swallowing without chewing.

This is something that places the resident at risk for choking, and this had proven to be the case for this resident. Prior to being admitted to the nursing home, the resident had a choking incident which led to an admission to the hospital intensive care unit. He also had at least three other known choking incidents at the nursing home before the fatal one. This was a resident who was clearly at risk for choking.

When there are threats to the health and well-being of nursing home residents, this must be addressed in the care planning process. There are six basic steps to the care planning process: (1) an assessment of the risks to the well-being of the resident, (2) development of a written care plan consisting of a series of steps or interventions that must be taken to address those risks, (3) communication of the contents of the care plan to the staff charged with carrying it out, (4) implementation of the care plan, (5) ongoing evaluation of the effectiveness of the care plan, and (6) revision of the care plan if there are changes in the resident’s condition or if it proves to be ineffective in practice.

The nursing home recognized that that the resident was at risk for choking, and consulted with a speech therapist for recommendations to help ensure that the resident was able to eat safely. These steps included obtaining an order for a modified diet to mechanical soft and mositening bread before serving. It also included supervision of the resident while eating, cutting food into small pieces, cueing the resident to eat nore slowly and to take sips of water in between bites. These steps were all incoporated into the resident care plan.

The resident’s family was permitted to bring food in for the resident periodically, but it had to be prepared and served by the staff. On the day of the incident, the resident’s family brought in a tuna melt sandwich. The sandwich was microwaved in the kitchen but not moistened. Due to the pandemic, the residents were all eating in their individual rooms. The resident’s meal was brought to him in his room by an aide who then left the room to pass additional meals. She returned to the room about 5 minutes later to assist the resident’s roommate.

When she got to the room, she heard a gasping sound coming from the resident and realized that he was choking. She called for help and began resuscitation efforts. However, the resident’s airway was filled with food which they were not able to successfully clear. The resident’s heart beat was lost and they were not able to regain it. An emergency room physician instructed the paramedics and staff to cease resuscitation efforts and the resident was declared deceased. Cause of death per the death certificate was anoxia due to choking on food.

There were a number of failures that led to the death of this resident.

First is that the resident was not being supervised while he was eating. The nursing home properly recognized that he was at risk for choking and took reasonable steps to identify a number of steps which could be taken to mitigate that risk. The key one here was supervision of the resident while eating – and this was not done here and was a violation of the resident care plan.

Why was there a violation of the care plan?

The simple answer is that the aide who served the meal did not know that he was supposed to be supercised while eating. She did not know this because no one told her. The resident care plan is more than paperwork – it is the game plan for the delivery of routine but necessary care for the resident. If the staff charged with carrying out the care plan doesn’t know what they are supposed to be doing, the effort in coming up with the care plan is wasted. More than that it represents a breakdown in the basic system that is intended to assure the safety of residents throughout the facility. It is a major systems failure.

The second reason was that the kitchen staff failed to follows the orders for mositening of the bread. The mechanical soft diet is supposed to help residents who have swallow difficulties and the moistening of the bread is intended to reduce the choking risk associated with bread. This step which was intended to mitigate the risk of choking was also not followed.

In the end, these failures resulted in the very preventable death of this resident.

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:

Fondulac Rehab resident chokes to death

Heartland of Moline resident develops pneumonia due to failure to follow diet orders

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Heartland of Moline resident develops pneumonia due to failure to follow diet orders

July 30, 2021 By Barry G. Doyle

IDPH has cited and fined Heartland of Moline nursing home after a resident there developed aspiration pneumonia due to the failure of the staff to follow orders for a modified diet.

One common condition that nursing home resident suffer from is dysphagia, or a swallowing dysfunction. This condition is commonly associated with the residual effects of a stroke, some neurological condition, generalized weakness, or advanced dementia. Swallow dysfunction can be a deadly condition in that it places the resident at risk for having a nursing home choking accident or developing aspiration pneumonia. Aspiration pneumonia occurs when foreign materials such as food, liquids, or saliva enter the lungs and cause an infection in the lungs.

When a resident is recognized as having a swallow dysfunction, evaluation by a speech therapist is necessary. The speech therapist will then make recommendations regarding the resident’s eating and diet. These recommendations are intended to combat the risks to the health and well-being of the resident, and will often include supervision and assistance with eating as well as modifications to the diet such as a puree or mechanical soft diet and/or thickened liquids. The recommendations of the speech therapist should be incorporated into an order by the physician and into the resident care plan.

The resident at issue suffered from dysphagia and was referred to a speech therapist. The speech therapist confirmed the presence of the swallow dysfunction and determined that a puree diet and moderately thickened liquids was necessary for the safety of the resident. Those recommendations were accepted by the resident’s doctor who issued the appropriate order.

However, shortly after these recommendations were made, the resident was seen with a half finished glass of regular water at lunch. Regular water is considered a thin liquid and giving this to the resident would be a violation of the recommendations of the speech therapist and of the doctor’s orders.

The following day, the resident was running a fever, was disoriented, and had crackling sounds in the lungs. The physician was notified, and he was sent to the hospital where x-rays confirmed the diagnosis of aspiration pneumonia. The resident was suffering from sepsis due to the pneumonia and was placed on comfort care measures only by his family.

This horrific outcome could have been easily prevented. The whole point of having a speech therapy evaluation done is to find out what has to be done to keep the resident safe while eating. When those recommendations (and the corresponding physician orders and care plan) are ignored, this subjects the resident to unnecessary risks of harm. In this case, the recommendation for thickened liquids was not followed by the staff, with a deadly pneumonia being the end result.

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:

Feeding tube error puts Burgess Square resident into heart failure

Click here to file a complaint about a nursing home with the Illinois Department of Public

Winston Manor resident chokes on peanut butter sandwich

July 20, 2021 By Barry G. Doyle

IDPH has cited and fined Winston Manor nursing home in Chicago after a resident there choked to death on a peanut butter sandwich.

One of the frightening possibilities that families face when they admit a loved one to a nursing home is that they could be the victim of a nursing home choking accident. Some nursing home residents suffer from dysphagia which is a swallow dysfunction. At times this is the result of a stroke, other neuromuscular condition, advanced dementia, or just generalized weakness. When a swallow dysfunction is present, the resident is at increased risk for choking. Customarily, this risk is addressed through a modified diet given per physician orders, treatment with a speech therapist, and through the care planning process.

The resident here was someone who was known to at risk for choking. In fact, this resident had experienced a choking incident about a year before the choking incident at issue and had also been admitted to the hospital for aspiration pneumonia. Aspiration pneumonia occurs when someone inhales a foreign substance whether it is food or a fluid into the lungs with an infection being the net result. The fact that this resident had this history demonstrated that he was at risk for choking.

The resident’s choking risk was addressed in the care plan where it called for the resident to receive extensive assistance while eating. Facility policies further called for residents who are at risk for choking to be monitored during meals.

On the day of the incident the resident was passed a peanut butter sandwich by one of the aides who then left him unattended. Shortly thereafter, the resident approached a staff member holding his hands to his throat, obviously choking. The staff member did the Heimlich. 911 was called and the resident was brought to the hospital where a large quantity of peanut butter was suctioned from his airway in the emergency room. He required intubation and was hospitalized for two weeks thereafter.

This was a very preventable accident which could have easily resulted in the death of this resident. The resident was a known choking risk, yet the staff handed him a peanut butter sandwich (something that is not always easy to swallow) and then left him unattended. The resident clearly had difficulty swallowing this given the large amount of peanut butter that was suctioned from his airway. Simply monitoring him as called for in the facility policies would likely have averted this choking incident from reaching the point where hospitalization was required.

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:

Chicago Ridge Nursing & Rehab resident chokes to death on sandwich

Alden Poplar Creek resident chokes to death

Bella Terra Wheeling resident chokes to death

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Bella Terra Wheeling resident chokes to death

December 1, 2020 By Barry G. Doyle

IDPH has cited and fined Bella Terra Wheeling nursing home after a resident there choked to death while eating dinner without supervision.

We have written in this blog many times about the significance of the care planning process, and the tragic results that can come from a lack of care planning, poor care planning, or the failure to actually implement the resident care plan. This incident arises from failing to understand what the interventions in the care plan are.

The care planning process begins with an assessment which is intended to identify the risks to the well-being and safety of the resident. At the same time, the Minimum Data Set (MDS) is completed which records the results of a comprehensive assessment of the resident. The MDS helps form the basis by which the nursing home is paid for services provided to the resident, so this must be completed under penalties of perjury. From the assessment, a care plan is completed which must then be communicated to the staff who in turn must carry out the care plan on a day-to-day, shift-to-shift basis. Finally the effectiveness of the care plan must be evaluated on an ongoing basis and then revised if it proves to be ineffective in practice.

For this resident, the MDS recorded that he required supervision with eating, and his care plan also showed he required supervision with eating due to dementia with behaviors. The speech therapist told the state surveyor that “supervision” meant having the resident in view while eating.

On the day of this nursing home choking accident, the aide brought the resident’s dinner tray into the room. The resident did not want to get out of bed, so the aide left tray with the resident after elevating the head of the bed to 90 degrees and then left the room. About five minutes later, the nurse was making her rounds and saw that the resident was slumped over, blue in the face, and gasping for air. She attempted the Heimlich, but was unable to clear the airway. The resident was pronounced dead by the paramedics who were called to the nursing home.

Staff interviewed by the state surveyor told the surveyor that “supervision” while eating meant reminding the resident to take small bites or that the food is on front of them and then periodically checking on them. The speech therapist explained that what the staff though was “supervision” was actually “cueing,” and that supervision meant keeping the resident within sight.

Here, this resident choked to death because there was a disconnect between what the care plan called for and what the staff thought it meant. This speaks to a lack of training of the staff. This shows a lack of interest in investing in the staff on the part of the ownership and management of the nursing home. Sadly, this is a common theme in the choices management makes in how to operate a nursing home. 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:

Resident at AHVA Care of Winfield chokes to death on peanut butter sandwich

Heartland of Moline resident develops aspiration pneumonia due to failure to follow diet orders

Resident chokes at Grove at the Lake

Winston Manor resident chokes on peanut butter sandwich

Hillcrest Retirement Village resident chokes to death

Resident chokes to death at the Moorings in Arlington Heights

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Aperion of Spring Valley resident chokes to death

November 9, 2020 By Barry G. Doyle

IDPH has cited and fined Aperion of Spring Valley nursing home after a resident there choked to death on a peanut butter and jelly sandwich.

Having their mom or dad choke to death in a nursing home is one of those things that is too horrible for children to imagine happening when their loved one is admitted to a nursing home. Sadly, given declining physical and mental conditions, it is a risk that some nursing home residents face.

The basic tool for addressing known risks to the health and safety of nursing home residents is the care planning process. The care planning process is a series of steps which must be taken to address the risks to the safety and well-being of nursing home residents. Choking risk can be addressed in the care planning process.

There are six basic steps to the care planning process: (1) an assessment of the threats to the safety and well-being of the resident, (2) development of the care plan which is an actual written document which outlines the steps or interventions that must be taken to address those threats, (3) communication of the care plan to the staff members charged with carrying it out, (4) implementation of that care plan on a day-to-day, shift-to-shift basis, (5) evaluation of the effectiveness of the care plan on an ongoing basis, and (6) revision of the care plan in the event that there are changes in the resident’s condition or needs or if the care plan as written proves to be ineffective.

When it comes to choking risk, the person who customarily evaluates the resident’s risk of choking is the speech therapist. There are a number of conditions which can place a resident at risk of choking. Dysphagia is the medical term for difficulty swallowing. Regardless of the medical condition which produced the difficulty with the swallow function, this is a prime driver of increased risk of choking. When combined with dementia, this can result in a high risk of choking because the resident may not be able to adjust his/her behavior in a way to minimize choking risk.

Besides outright choking, difficulty with swallowing can lead to aspiration pneumonia as food particles entering the airway and make their way into the lungs. The body’s reaction to having food enter the lungs is to cough in an effort to expel the foreign substance. Observation of coughing while eating may be a sign that the resident has swallow deficits.

When the speech therapist determines that a resident is at increased risk of choking, there are a number of recommendations that are normally a part of the care plan. These include therapy, supervision while eating, behavioral cues, and modifications to diet.

The resident at issue had a diagnosis of dysphagia and suffered from dementia. She had a history of multiple episodes of aspiration pneumonia. She was well-known to the staff to someone who could not follow swallow strategies to take small bites and eat at a slow pace. While she was being fed, she could often be heard coughing. Her care plan included supervision while eating, to serve the resident a prescribed diet, and to monitor the resident while eating for difficulties with swallowing.

On the day of this nursing home choking accident, the residents were not able to eat in common areas due to COVID restrictions, so they would be brought to their doorways while being fed. Each resident had a specific snack that was supposed to be provided to them. This resident was supposed to receive a pudding snack, but the aide passing the snacks did not see that the resident had been provided with a designated snack, so she provided the resident with a peanut butter and jelly sandwich per the resident’s request.

After passing the peanut butter and jelly sandwich to the resident, the aide continued to pass snacks to other residents, leaving the resident unattended and unsupervised. About 10-15 minutes after the resident was given the sandwich, a physical therapy assistant working with a resident across the hall looked out the door and saw that there was something wrong with the resident. He went over to the resident and asked what was wrong, and she said, “I am choking.”

The physical therapist pounded the resident on the back and went and got the aide, who in turn summoned a nurse. A code was called, and efforts were made at clearing the airway and doing the Heimlich. The resident lost consciousness and was placed on the floor while CPR was performed. However, she lost her pulse, and by the time that paramedics arrived, she could not be revived. She was declared deceased without being brought to the hospital. Cause of death per the death certificate was asphyxiation and choking on a sandwich.

There are a couple of shortcomings in the care that this resident received.

The first is that she was not given the snack that had been selected for her by the dietary staff. Pudding (the selected snack) is much less thick than a peanut butter and jelly sandwich and is less likely to cause an airway obstruction. Instead of verifying what should be given to the resident, the aide left that in the hands of the resident who likely never understood what her needs were.

Second, the resident was not supervised while consuming the snack. This resident had a well-known risk of choking starting with her dementia and dysphagia, her history of having episodes of aspiration pneumonia, her well-known behavior of not following safe eating practices, and her documented history of coughing while eating. This was a resident who required close supervision while eating and that level of supervision called for in her care plan was simply not provided. No doubt that COVID made this more difficult, but it needed to be done to assure the safety of this resident.

Delivery of good care in a nursing home isn’t always easy, but it is possible. However, it is that much harder when there is not enough staff on hand to get the job done. Sadly understaffing a nursing home is a feature and not a bug of 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. 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:

Aspen of Silvis resident chokes to death due to care plan violation

Heartland of Moline resident develops aspiration pneumonia due to failure to follow diet orders

Resident chokes to death at River Bluff nursing home

Aperion of Spring Valley resident suffers fatal brain bleed in fall

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Alden Poplar Creek resident chokes to death

September 15, 2020 By Barry G. Doyle

IDPH has cited and fined Alden Poplar Creek nursing home in Hoffman Estates after a fatal choking accident involving one of the residents.

There a number of conditions which can place a nursing home at risk for choking. Among these are difficulty with swallowing (known as dysphagia), dementia, poor dentition, Parkinson’s disease, and a number of other neuromuscular disorders. A resident’s risk of choking can be evaluated by a speech therapist in a clinical setting or the resident can be sent to a hospital for a video swallow study.

However a resident is determined to be at risk of choking, once that determination is made, that risk must be addressed in the resident care plan. One thing that a speech therapist does is assess deficits in the resident’s swallowing function and then recommends various strategies to minimize the risk of choking. Often these will take the form of a modified diet and supervision at meals. These recommendations should be tailored to the particular needs of the resident and should be incorporated directly into the resident care plan so that all of the staff charged with caring for the resident know what steps should be taken to keep the resident safe.

Here, the resident was at risk for choking. He had been diagnosed with dysphagia, Parkinson’s, and dementia. The resident had a video swallow study done at the hospital after a prior choking episode. This confirmed that the resident had swallowing difficulties. When he returned to the nursing home, the speech therapist made a number of specific recommendations regarding the resident’s eating which were intended to address the risk of choking. These included: one-to-one supervision during meals and cuing the resident to take sips of water in between bites because due to the Parkinson’s, he often did not swallow all of the food in his mouth on the first effort. The resident’s care plan addressed the risk of choking, but did not include all of the recommendations made by the speech therapist.

On the day of this nursing home choking accident, the resident was seated in a small dining room in the memory care unit. He had finished eating but the tray was left in front of him with food still on the tray, as well as some food his family had brought to the facility for him to eat. The staff in the dining room were all attending to other residents. The aides heard a gurgling sound coming from the resident and brought the nurse in. The nurse attempted the Heimlich, but could not clear the airway and lowered the resident to the floor. A nurse practitioner and a doctor who happened to be in the building came to assist with resuscitation efforts. After paramedics arrived, they intubated the resident but were unable to revive him. He was pronounced dead at the nursing home. Cause of death was asphyxia due to choking on a food bolus.

There were a number of issues with the care that this resident received which contributed to his death. First, the care plan failed to include the recommendations made by the speech therapist. The whole point of having a speech therapist make recommendations is to find out what has to be done to assure the safety of the resident. If those recommendations are not incorporated into the care plan to be carried out on a day-to-day, shit-to-shift basis, then the recommendations have no real value. One of the crucial recommendations that was made is that the resident needed one-to-one supervision while eating, and if a resident is left with a food tray and other food in front of him, then there is a risk due to the resident’s dementia that they will go ahead and continue eating with no supervision. That is what occurred here.

Second, the staff left the resident’s tray in front of him thinking that he was done eating. This is contrary to what the speech therapist said needed to be done, as well as the facility’s own policies and procedures. Had these procedures and recommendations been followed, this resident would not have died in this manner.

Having staff that is unaware of the facility’s own policies and procedures is a mark of poor training. Nursing homes are businesses and well-run businesses have policies and procedures (“this is how we do things here”) that tell them how to deliver the basic services that the business provides, and the staff must be trained on them. Without training of the staff, good policies do nothing more than fill binders on a shelf, and nursing home residents deserve better than that.

Sadly, having a poorly trained staff is entirely consistent with now most nursing homes operate, because training staff costs money and that cuts into profits. 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:

Resident at AHVA Care of Winfield chokes to death on peanut butter sandwich

Hillcrest Retirement Village resident chokes to death

Bella Terra Wheeling resident chokes to death

Heartland of Moline resident develops aspiration pneumonia due to failure to follow diet orders

Resident chokes to death at the Moorings in Arlington Heights

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

IDPH stops investigating abuse and neglect cases in nursing homes

August 26, 2020 By Barry G. Doyle

Recent news reports has shown that IDPH stopped investigating allegations in abuse and neglect during the period between approximately March 15 and June 30.

By way of background, the Illinois Department of Public Health is the agency which inspects nursing homes and issues citations for violations of state and federal regulations. When a nursing home has a citation issued to it, they must submit a plan of correction to show what they will do to bring the nursing home back into compliance. This often includes retraining of the staff or repair and inspection of broken equipment. The citations are usually accompanied by a fine which usually tops out at $25,000 for the most serious violations that result in significant injury or death to the resident. Citations may also result in issues with the nursing home’s license or with their Medicare star ratings.

The date that IDPH stopped doing the abuse investigations of course correlates with the onset of the coronavirus pandemic. There can be no doubt that the pandemic has hit the nursing home industry particularly hard, especially in terms of resident and staff illnesses and deaths, and has made a hard task even harder. However, the extra demands brought on by the pandemic does not mean that other care needs of the residents could not/should not be met.

(Related resource: IDPH Long Term Care Facility Outbreaks COVID-19 – searchable database you can use to find out which facilities have COVID-19 case, how many, and how many deaths)

One of the recommendations that we make to families with a loved one in a nursing home is to be a frequent, but unpredictable visitor. In other words, visit often, but not on a set schedule so that the staff always has to be on top of their game with your family member. For example, if the staff know that you always come Tuesday evening, you can be sure that things will look good Tuesday evening … which may be a different story from Friday morning. We also recommend that you be pleasant but assertive regarding your family member’s care. None of this has been possible as of late with restrictions on visitors in nursing homes.

Over the last several months, we have heard from a number of families who have been very upset about their limited access to their family members, and justifiably so.

Investigations of abuse and neglect in nursing homes are often triggered by mandatory reporting by the nursing home to IDPH after an incident occurring in the nursing home or by a report submitted by a hospital or doctor who was concerned about the condition of a nursing home resident who was sent out for care. While IDPH has been inspecting nursing homes for compliance with infection control measures, the inability of family members to get into the nursing home left IDPH as one of the last lines of defense when it comes to stopping nursing home abuse and neglect.

The pandemic has doubtless made many of the basic functions that need to be carried out on a day-to-day basis much more difficult and this has opened the door to many of the types of preventable injuries much more likely to occur. Without even trying to address this in an exhaustive way, these are some of the ways:

Bed sores

The need to observe proper infection control measures makes going in an out of rooms something that takes longer, which means that the simple act of turning and repositioning bed-bound and chair bound residents is going to be harder to get done. Further, that also feeds in to it taking longer to change a resident after an episode of incontinence. This also makes it more difficult to make sure that residents get adequate amounts of food and liquid.

Why is this important? Because immobility, incontinence, and poor nutritional status are three of the main factors which place residents at risk for developing bed sores and addressing these issues are key steps for promoting healing after someone has already developed a bed sore.

Nursing Home Falls

One of the main stays for fall prevention is to keep residents in a common area where they can be easily monitored by staff. One of the ways of preventing the spread of the coronavirus is to keep residents in their rooms which neutralizes the effectiveness of this tactic.

Promptly responding to call lights and assisting residents to the bathroom when they need it are also key fall prevention measures. Just as with turning and repositioning, this is a more difficult task in the current environment.

One of our core beliefs is that constant or intermittent confusion is a strong risk factor for nursing home falls because the resident cannot be counted on to make good decisions for their own safety or ask for help. The combination of lots of social isolation and the staff being masked and gowned constantly is something that is likely to lead to further cognitive decline.

Past that, residents have a diminished ability to walk and exercise which leads to further decline in range of motion, strength, and balance.

Choking

Residents are no longer being served meals in dining halls. This means that they are generally eating alone in their rooms which means that residents who are experiencing declines in their ability to swallow are not being noticed and referred for swallow evaluations by speech therapy. Other residents who are already under care plans for choking risk are likely receiving lower levels of assistance and supervision with meals.

****

One of IDPH’s roles is to prevent nursing home residents from suffering unnecessary injuries, illnesses, and wrongful deaths, and with families unable to watch out for and advocate for their loved ones, carrying out that responsibility was more important than ever. Supposedly, IDPH has made a dent in the backlog of investigations that piled up while they stopped doing investigations, but the passage of time and the press of business makes it every more likely that those investigations will not be as thorough as they should be.

Unfortunately, failure was already baked into the system by which care was being provided in nursing homes in Illinois. For more information on why that is the case, order our FREE report, Built to Fail. If you have a loved one who you believe has suffered unnecessary injuries or been the victim of nursing home neglect or abuse during this time, please contact our experienced Chicago nursing home lawyers. The initial call and meeting are free, and there is no obligation to hire us if you do call. We serve nursing home residents and their families throughout the State of Illinois.

Riverview Rehab resident chokes to death

July 21, 2020 By Barry G. Doyle

IDPH has cited and fined Riverview Rehab nursing home in Elgin after a resident there choked to death while being fed by an aide.

One of the functions that a speech therapist plays in the care of nursing home residents is assessing the resident’s ability to eat safely. This is done by assessing the resident’s swallow function. If there are issues with the resident’s swallow function, then the speech therapist will make recommendations for a modified diet and other safety precautions. Left unaddressed, difficulties with swallowing can lead to a nursing home choking accident or aspiration pneumonia.

The recommendations made by the speech therapist are usually incorporated into the resident’s care plan or physician orders. Either way, these precautions are critical to safety and well-being of the resident and must be carried out on a day-to-day, shift-to-shift basis. Failing to do so can lead to disastrous outcomes.

The resident at issue was assessed by the speech therapist who determined that the resident was at risk for aspiration because of dysphagia (difficulty swallowing), brain injury, and communication deficits. The resident was placed on a modified diet with mechanical soft foods and thickened liquids. The resident had a history of eating very quickly, but was allowed to feed herself with supervision. The staff was specifically instructed to make sure that the resident finished each bite and swallowed before taking the next one.

On the morning of the accident, the resident was being fed by an aide who was aware that she was at risk for aspiration. The resident started feeding herself but was eating too quickly so the aide took the meal away and began to feed her. However, the resident did not want to be fed, so the aide returned the tray to her and continued to watch her eat. Gradually, the aide came to realize that the resident was “not looking good,” so she she went and got another aide who told her to get a nurse. When the nurse arrived, the resident almost immediately lost consciousness, so the nurse cleared food from her mouth and began to do CPR.

911 was called, but when they arrived the resident had no pulse. They were able to regain a pulse and brought the resident to the emergency room. The resident was admitted to the intensive care unit, but the extent of the brain damage was so significant that the family placed her on hospice. She died six days after the choking incident. Cause of death per the death certificate was “Complication from aspiration of food bolus.”

There were many things that the nursing home did right here, but a couple of breakdowns in the care led to the death of this resident. On the plus side, they got a proper assessment done of the swallow function and came up with a modified diet and steps to address her risk of choking. The fact that the she was at risk for choking and what should be done was also properly communicated to the staff on the floor.

Where the care that this resident received failed was in two respects. First, the tray was returned to the resident after she demonstrated impulsive eating behaviors and would not be fed by the staff. The speech therapist and the Director of Nursing both agreed that the proper course of action here would have been to take the tray away, check the resident for pocketing of food, and alert the nurse. Second, the aide failed to recognize that the resident was choking, failed to alert the nurse immediately (rather than another aide), and failed to take steps to clear the resident’s airway. The minutes of delay when the resident’s airway was compromised was critical time lost to indecision.

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:

Fondulac Rehab resident chokes to death

Fatal choking accident at Warren Barr North Shore

Fatal choking accident at Iona Glos

Resident chokes to death at Grove at the Lake

Aspen of Silvis resident chokes to death due to care plan violation

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Fatal choking accident at Spring Creek in Joliet

May 22, 2020 By Barry G. Doyle

IDPH has cited and fined Spring Creek nursing home in Joliet after a resident there choked to death due to a lack of care planning.

The care planning process is the basis for for much of the routine care that is provided on a day-to-day basis in nursing homes. The process starts with an assessment which identifies the risk to the health and well-being of the resident and then puts into place interventions which need to be carried out by the staff on a day-to-day, shift-to-shift basis. The care plan must be communicated to the staff, and its effectiveness must be evaluated on an ongoing basis and changed if it proves ineffective in practice, fails to meet the care needs of the resident, or if there are changes in the resident’s condition.

Choking is something that may pose a risk to the health and well-being of nursing home residents. Residents may have difficulties with chewing or swallowing due to neurological or muscular disorders. Cognitive or behavioral issues might compound the problem by leaving the resident without real means to manage their behavior or with a lack of insight as to the risk that certain foods may pose to them. When this is the case, a well-done care plan usually includes a consultation with a speech therapist to help determine what sort of diet consistency is safe for the resident, assistance with eating which is provided at a feeder table in the dining room, and close supervision around food.

The resident at issue had a number of long term medical and cognitive issues and had been admitted to the nursing home from a group home. Among these issues were profound intellectual disabilities, a history of intracerebral hemorrhage, dysphagia (difficulty with swallowing), and Parksinson’s Disease. Around the time of his admission, the social services director spoke with the group home that the resident came from and was told that the resident engaged in pica (putting nonfood items in his mouth) and grabbing food off other resident’s plates. In short, this was a resident who was at very high risk for choking.

Given his risk profile with physical and mental/cognitive limitations that placed him at risk for choking, putting a choking prevention care plan into place was absolutely necessary. The social services director told the surveyor that she put one in place for the resident at the time admission, but that was never done. There was no referral to a speech therapist, no modified diet, no assistance or supervision with eating.

Even without the choking risk being addressed in the formal care planning process, there were other windows in which this resident’s choking risk could and should have been addressed. After the resident was admitted to the facility, nurses on the floor noted on five different occasions within the two weeks before the resident choked that the resident was taking food from other and residents and/or jamming food into his mouth.

On the day of this nursing home choking accident, the staff noticed that the resident was pushing his wheelchair through the dining room and was turning blue. The nurses swept his mouth clear of scrambled eggs and initiated CPR. 911 was called and when the paramedics arrived, they cleared additional eggs from the resident’s airway. When they attempted to intubate the resident, more eggs interfered with the placement of the tube. He was brought to the hospital where still more eggs were retrieved from the resident’s airway. The resident did not survive and was declared deceased in the emergency room.

There were a number of basic breakdowns in the care planning process that resulted in the wrongful death of this nursing home resident. First, even though the resident was clearly at risk for choking, there was no care plan put into place during the formal care planning process. After that, there were multiple episodes of behaviors which should have suggested to the nurses who were noting his behaviors of grabbing food and stuffing his mouth full that this was a resident who was at risk for choking and to see what the care plan was to address this. Discovery that this resident’s choking risk had not yet been addressed in the care plan should have led to a revision of the care plan. This is an outcome that could have been avoided by simply placing the resident at a feeder table where he could have been closely supervised during meals.

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 and understaffing of nursing homes. 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:

Resident at AHVA Care of Winfield chokes to death on peanut butter sandwich

Chicago Ridge Nursing & Rehab resident chokes to death on sandwich

Resident chokes to death at Rosewood of St. Charles

Fatal choking accident at Glenwood nursing home

Resident chokes to death at The Moorings in Arlington Heights

Resident falls from bed at Spring Creek

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Resident chokes to death at Warren Barr North Shore

January 28, 2020 By Barry G. Doyle

IDPH has cited and fined Warren Barr North Shore nursing home in Highland Park after a resident there choked.

Broadly speaking, we all are at some risk of choking, but when it comes to nursing home residents, there are two basic categories of residents who are increased risk of experiencing nursing home choking accidents. One category is residents with chewing or swallowing difficulties due to some physical issue. These residents are usually assessed by a speech therapist, receive a recommendation and an order for a mechanically altered diet to reduce choking risk, and are supervised while eating at a so-called “feeder table” in the dining room. The other category of resident who has a behavioral issue, typically relating to the consequences of stroke, brain injury, or some form of psychological disorder, which causes them to eat in an unsafe manner. These residents require close supervision while eating because of their lack of control over their own behavior.

The resident involved in this fatal choking accident fell into the second category. He was only 46 years old and suffered from frontotemporal dementia which led to a lack of control in eating. He would shove food in his mouth without chewing, would take food off other resident’s trays, and overeat to the point of vomiting. According to his Minimum Data Set, he required the supervision with one person assist while eating.

On the day of the incident, a nurse brought the resident’s tray into his room. The resident was seated upright on his bed, eating and watching television. She left the room to attend to other resident’s but did not take his tray with her. When she returned about 15 minutes later, he was unconscious, blue in color, and unresponsive. When they tried to revive him, they found his mouth stuffed with food. He was pronounced shortly thereafter.

This was a highly preventable death. All that was needed to stop this from happening was to provide this resident with the supervision that everyone knew that he needed. Instead, the nurse left him alone with his tray while she went to do other things. Had the tray been taken away or someone else found to supervise this resident, this death would not have occurred.

The real question of course is why did the nurse leave the resident unattended? The answer probably relates to understaffing of the nursing home which is a deliberate feature of 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. 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:

Resident chokes to death at Grove at the Lake

Fatal choking accident at Iona Glos nursing home

Winston Manor resident chokes on peanut butter sandwich

Resident chokes to death at The Moorings in Arlington Heights

Resident suffers facial burns in smoking accident at Elevate Care of Waukegan

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Fatal choking accident at Hillcrest Retirement Village

January 21, 2020 By Barry G. Doyle

IDPH has cited and fined Hillcrest Retirement Village in Round Lake Beach after a resident suffered two choking incidents over a three day period with the final one resulting in the death of the resident.

The resident was readmitted to the facility after being hospitalized due to aspiration pneumonia. Aspiration pneumonia occurs when something (commonly food) enters the lungs and causes an infection. People who have difficulties with swallowing often experience aspiration pneumonia because the swallow process for them is disorganized and as a result they end up having food particles enter the lungs, resulting in the infection. When the resident was readmitted to the facility, he was noted to have diagnoses of dementia and dysphagia (swallowing difficulty) and his care plan included monitoring for signs and symptoms of choking, coughing, and pocketing of food while eating. His diet order was for pureed foods and honey thickened liquids. This diet order was intended to reduce the risk of choking.

Additionally, he underwent three weeks of speech therapy. One of the important tasks that a speech therapist handles in a nursing home setting is treating residents with swallowing difficulties and making recommendations regarding diet orders. While many nursing home residents would prefer to eat as normal a diet as possible, getting a proper diet recommendation from a speech therapist is a key measure in reducing the risk of a nursing home choking accident. After the three weeks of speech therapy, the speech therapist recommended that the resident’s diet be upgraded to a general diet with no restrictions, and the resident’s doctor entered the order.

Two days after the resident’s diet was upgraded, he experienced his first choking incident. He was eating dinner when his face began to turn blue. One of the aides working in the dining room gave him back blows, and this was sufficient to expel some of the fish and bread he was choking on, and the staff was able to reach into his mouth and clear the remaining food away.

The nurse on duty at the time of the first choking accident noted the occurrence on the resident’s chart. However, she never notified the resident’s doctor or the speech therapist that there had been a choking incident. Both the doctor and the speech therapist told the state surveyor that had they been notified of this choking incident, they would have downgraded the resident’s diet to include foods with a consistency that poised a lower choking risk. The facility’s policies and procedures also permitted members of the nursing staff to downgrade a resident’s diet if there were safety concerns. However, the nurse was apparently unaware of that and believed that simply documenting the fact that a choking accident had occurred was enough.

Sadly, it wasn’t.

Three days later, the resident was eating dinner again, with the unchanged general diet order – despite the choking incident just a few days earlier. The resident again choked on food, but this time, lost consciousness and became pulseless and unresponsive. Paramedics were called and CPR was performed. The paramedics attempted intubation, but they were unable to place the tube due to the airway being obstructed by food. The resident was brought to the hospital where he died two days later.

Care in a nursing home setting is often looked at as being provided by an interdisciplinary team which obviously includes the nursing staff, but also includes professionals such as the speech therapist and the resident’s doctor. This is the kind of tragic outcome that results when the members of the team do not communicate with one another. It was the job of the nurse to let speech therapy and the doctor know about the incident, and both stated that they would have downgraded the resident’s diet, but they never were given the chance to do so. This is also the kind of outcome that results from a member of the nursing staff failing to appreciate the hazard that a choking incident represents and failing to know what tools were available to her to address that hazard. The nurse had the ability to downgrade the diet independent of the doctor and speech therapy. Given the opportunity to prevent this outcome by 1) notifying the doctor, 2) notifying speech therapy, and 3) acting independently to downgrade the diet, she did nothing, and the wrongful death of this resident was the result.

While a heavy dose of fault lies on the nursing staff, the role of the speech therapist also deserves careful consideration. It was the decision of the speech therapist to upgrade the resident from a puree diet to a general diet which set the stage for this outcome, and that decision deserves special scrutiny. It is important that this is done at the outset of any case because speech therapists are generally not direct employees of a nursing home, but are independent contractors.

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:

Riverview Rehab resident chokes to death

Fall from mechanical lift at Hillcrest Retirement Village

Fatal choking accident at Warren Barr North Shore

Resident chokes to death at Rosewood of St. Charles

Resident chokes to death at The Moorings in Arlington Heights

Click here to file a complaint about a nursing home with the Illinois Department of Public Health.

Fatal choking accident at River Bluff nursing home

November 16, 2019 By Barry G. Doyle

IDPH has cited and fined River Bluff nursing home in Rockford after a resident there choked to death on a peanut butter and jelly sandwich.

There are certain medical conditions which can increase the risk of a nursing home resident having a choking accident. One of these is Alzheimer’s; another is having a history of having had a stroke. With Alzheimer’s patients the advancing disease may cause the brain to no longer properly process the commands to chew and swallow, leading to an increased risk of choking. With regard to a history of stroke, the damage from the stroke may cause deficits in chewing and swallowing which lead to an increased risk of choking.

As with any risk to the health and well-being of a nursing home resident, the risk of choking is one which should be addressed in the resident care plan which then must be communicated to the staff charged with carrying out the task of supervising the resident while eating and then whatever steps are provided for must be carried out on a day-to-day, shift-to-shift basis. When the steps outlined in the care plan are not carried out, this exposes the resident to an increased and unnecessary risk of experiencing a choking accident.

The resident at issue here was at risk for choking. She suffered from Alzheimer’s and apparently had a stroke in the past as also suffered from hemiplegia (paralysis on one side of the body) and dysphagia (difficulty swallowing), both of which are common residuals from having suffered a stroke. She also had experienced a choking incident a year earlier in which she choked on a piece of a grilled cheese sandwich.

To address the choking risk, the nursing home had a care plan which included a mechanical soft diet following an assessment and recommendations from a speech therapist. There was also a physician order in place for a mechanical soft diet. A mechanical soft diet is often used to address a resident’s choking risk and consists of items which are easily swallowed with minimal chewing effort.

On the day of the accident, the resident was eating dinner in the dining room of the memory care unit with two aides at the table. She did not want the chili that was being served that night, so the aide assigned to help feed her that evening made a peanut butter and jelly sandwich for her. She prepared this, in her words, “the same way I would do for my kids” with jelly packets, creamy peanut butter, and bread. As the resident ate the sandwich, she began to show signs of choking. One of the aides brought in a nurse who performed the Heimlich maneuver which cleared small amounts of the sandwich from her airway. She was brought by paaramedics to a local emergency room where she was pronounced deceased.

So what was the problem here that led to the wrongful death of this nursing home resident? There are two major issues:

The aide caring for her at the time of this choking accident did not know that she was on a mechanical soft diet. Assuming that things were done properly, she would have received a mechanical soft diet from the kitchen, but having the staff who was supervising this resident while she ate not know what her diet was represents a serious breakdown in the delivery of care, as it meant that neither the care plan not the doctor’s orders were being carried out.
The sandwich that she made was not safe for this resident to eat. The tackiness of the peanut butter is something that requires more swallow effort than a resident on a mechanical soft diet should be expected to offer, so making a sandwich like you do for your kids is not an option for residents on a mechanical soft diet. There was an option for these residents to get a peanut butter and jelly sandwich, but that involved sandwiches that were premade by the kitchen in a way that blended the peanut butter and jelly to thin the peanut butter out to make it easier to swallow. These staff members did not realize that what was required to provide a peanut butter and jelly sandwich and did not know that there was a safe alternative available in the kitchen.

A series of simple failures leading to a tragic result.

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: