Allure of Moline Cited After Resident on Pureed Diet Choked to Death on Hot Dogs

The Illinois Department of Health has cited and fined Allure of Moline when a resident who required a pureed diet and constant supervision due to choking risk was allowed to leave the dining room unsupervised, grabbed hot dogs and buns from another resident’s plate, and choked to death. The facility had no procedures in place to prevent the resident from stealing regular food despite knowing he frequently grabbed food from other residents’ trays.

The resident in question was admitted following a stroke that left him partially paralyzed on his right side, unable to speak, and with difficulty swallowing. His medical orders specified a pureed diet with nectar-thickened liquids due to “choking and aspiration risks” and required he “must be supervised closely in dining room.” His care plan documented he was “at risk for choking due to removing food and eating from other resident’s trays that is not on prescribed diet” and specified he “was to only eat with supervision.”

Despite these clear requirements, the resident was well-known for grabbing food. Staff described how he “seemed to understand what was being said to him, and he knew he was not supposed to have solid foods.” However, “he would always be grabbing and sneaking food off of trays and hurry and stuff it in his mouth.” Multiple staff members witnessed him taking sandwiches, burgers, and pork tenderloins. One nursing assistant said “when he would get food he would stuff it in his mouth really fast because he knew he was not supposed to have it.”

The resident could propel his wheelchair with his left foot and move freely throughout the facility. One nursing assistant explained “sometimes the staff would take him out of the dining room and he would just go back in, and he would grab at food.” Another said he “was non-compliant with his puree diet and was quick to grab anything and try to eat.”

Despite this known behavior, the facility had no procedures in place. One nursing assistant stated “there was no special rules or procedures to ensure he left the dining room without grabbing food as he was leaving. It was just common knowledge among the aides to just keep an eye on him.” Another confirmed “there was no procedure or protocol in place at that time to ensure he got out of the dining room without stealing food from plates.”

During the dinner meal, the resident finished his pureed meal and wheeled himself across the dining area toward his room. Staff were occupied feeding other residents and responding to call lights. Shortly after, around 6:45 PM, a nursing assistant noticed the resident “sitting at the beginning of the hallway in obvious distress, face pale in color.” Two nursing assistants “rushed to assist resident and noted he was choking and started the Heimlich maneuver immediately.”
A nurse intervened and “a partial bolus of food was removed from his mouth and the Heimlich was continued.” The administrator, working as a nurse that evening, described: “You could tell his mouth was full of food, and as she was pulling it out, it appeared to be hot dogs and buns.” Emergency medical technicians arrived and attempted “suctioning, IV medications, chest compressions, and intubation.” However, they “tried to intubate him, but could not get the tube in, and the resident could not breathe.” After forty minutes of resuscitation efforts, the resident was pronounced dead at 7:27 PM.

The administrator acknowledged the failure: “The resident was always trying to get food off plates in the dining room. He was sat next to those residents needing fed, but he moved so fast. He must have picked up food while he was moving through the dining room. During that time, the resident needed better supervision. Should have been watching him and taking him out of the dining room. We did fail him somewhere, I guess.”

One nursing assistant recalled that another nurse “had just passed the resident and he had food in his mouth but did not do anything.” The nurse confirmed “there was no procedure or protocol in place at that time to ensure he got out of the dining room without stealing food from plates.”

After the resident’s death, the facility immediately implemented changes. They revised their meal supervision policy, audited care plans for all residents requiring modified diets and supervision, and conducted an environmental review of the dining room. Residents on pureed diets are now seated together “for resident dignity and safety/supervision with a staff member assigned to their table,” and residents at risk are escorted from the dining room after meals. All licensed nursing staff were in-serviced on the new policy. The facility held an emergency quality improvement meeting and decided “hot dogs will no longer be served in the building.”

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