The Illinois Department of Health has cited and fined Elevate Care Northbrook when a resident with severe swallowing difficulties and strict aspiration precautions choked to death on a whole hot dog in a bun that staff failed to cut into small pieces. Staff reported the resident was alert and responsive when paramedics arrived, but the ambulance crew reported finding her unresponsive and alone with oxygen saturation of 60% and equipment not connected to oxygen.
An Elevate Care Northbrook resident was admitted with multiple diagnoses including acute respiratory failure, dysphagia (difficulty swallowing), and chronic obstructive pulmonary disease. Her assessment documented swallowing problems including “holding food in mouth/cheeks” and “complaints of difficulty or pain with swallowing.” She required supervision or touching assistance with eating.
The resident was under speech therapy evaluation for dysphagia. The speech therapist stated clearly: “She has difficulty swallowing, therefore we prescribed liberalized diet with no red meat. I recommended to eat slowly with small bites, small sips. She is on full aspiration precautions due to long history of dysphagia.” The therapist emphasized: “Staff has to remind her to eat slowly. She needs to be sitting upright when eating; eat slowly; small sips and bite slowly; if there is a need that she eats big chunk of food, make sure she cuts her foods in small pieces.”
Despite these instructions, multiple staff were unaware of the resident’s swallowing difficulties. One nursing assistant stated: “We don’t need to tell her to eat slowly, or tell her to cut her foods in small pieces. Not that I know of that she is on aspiration precautions.” Another said: “She does not have any dysphagia, and she can eat whatever she wants to eat.” The director of food services stated: “I am not aware that she has swallowing difficulties.”
Most critically, the resident’s swallowing difficulties were not addressed in any care plan. Her care plan only documented nutritional status with interventions about food preferences and offering snacks. The director of food services admitted: “I initiated dietary care plan, only for the menu choices. Other than that, I did not evaluate her for any swallowing difficulties.”
During dinner, the resident was served a whole turkey hot dog in a bun. The supervising nursing assistant explained: “I served her dinner, I let her cut the foods because she refused. I was standing by the table supervising her, looking at her while she eats. I didn’t say anything or tell her to eat slowly or small pieces and bites. I just stood there and watched her, then she started coughing and holding her throat.”
Staff immediately performed abdominal thrusts and called for help. One nurse described: “I placed my both hands under rib cage and did abdominal thrusts.” Another stated: “I wrapped my arms around her waist, below sternum, and made an upward thrust. I saw the food coming out from around her mouth. I swiped it out with my fingers. She started breathing again and said she can breathe. Her oxygen saturation was 97%.”
Multiple staff members consistently reported the resident was alert and responsive when paramedics arrived. The facility’s incident report stated she “was alert, responsive and breathing via nonrebreather mask with SpO2 level of 97% when picked up by paramedics.” One nurse stated: “She was alert, awake, breathing with nonrebreather mask” when paramedics transported her. Another nurse said: “She is alert and can answer all my questions” approximately 5-10 minutes before emergency services arrived. A nursing assistant stated: “She was alert when she left. I was in the room when paramedics came. I did not leave her.” However, the ambulance report documented a significantly different account: “Upon arrival, patient was found unresponsive laying in bed. Crew noted a SpO2 of 60%. Patient had a nonrebreather mask but not connected to any oxygen. She was not responsive to verbal and painful stimuli.”
The paramedic provided additional detail: “When I saw the resident, she was lying in bed and had shallow respirations. She was not responsive to verbal and painful stimuli, we called out her name, there was nothing. There was no eye opening. SpO2 was 60%. There was no facility staff in the room when we get there. So, I went back out of the room and everybody, which I am sure were staff working in the facility, were just standing around. No one can tell me anything about a DNR.”
This created a clear conflict between the two accounts. Facility staff consistently stated the resident was alert, awake, and responsive with oxygen saturation of 97% when paramedics arrived and that staff remained with her. The ambulance crew reported finding her unresponsive, alone, with oxygen saturation of 60% and oxygen equipment not properly connected.
During transport, the ambulance report documented the resident “became less responsive, sats dropped below 50% despite supplemental oxygen and bag valve mask. Patient lost her pulse at that time.” She “expired during transport to hospital after choking episode with respiratory arrest.”
The paramedic also noted: “When we moved her over to our cot, we noticed a bruise underneath the sternum, under breasts area. That is not the proper placement of the hands when doing Heimlich maneuver.” The paramedic also stated: “If resident is already unresponsive, they have to do CPR,” suggesting concern about whether appropriate care was provided if the resident had become unresponsive.
When investigators interviewed staff about proper Heimlich technique, responses were inconsistent and often incorrect. One nursing assistant described only back blows with no mention of abdominal thrusts. Another said to “do CPR and start chest compressions” when asked about choking, confusing choking response with cardiac arrest protocol.
The medical director acknowledged the systemic failure: “For residents with dysphagia or difficulty swallowing, we have to follow whatever the speech therapy recommends. If it says small bites, they should be getting small bites. Follow the guidelines and make sure staff follow instructions. And it should be care planned and needs to be in the interventions.” None of this was done.
The facility failed on multiple critical levels: they did not include the resident’s swallowing difficulties in her care plan despite clear documentation of dysphagia, many staff were unaware she had swallowing problems or was on aspiration precautions, staff failed to cut her food into small pieces or remind her to eat slowly as ordered, and there was a significant discrepancy between staff reports that the resident was alert and responsive with properly connected oxygen when paramedics arrived versus the ambulance crew’s report that she was unresponsive, alone, and had oxygen equipment not connected.
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.
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