Scott County Nursing Center Failed to Notify Doctor After Resident Choked, Leading to Second Choking Episode

The Illinois Department of Health has cited and fined Scott County Nursing Center when a resident choked twice within five days, but staff failed to notify the physician after the first incident or change her diet, contributing to a second choking episode that required the Heimlich maneuver. The facility’s failure to recognize warning signs and implement appropriate interventions put the resident at serious risk.

The resident had returned to the facility after a hospital stay for a stroke, where a video swallow study revealed she had penetration with thin and mildly thick liquids, meaning food would reach the level of her trachea before spontaneously clearing. Speech therapy initially recommended honey-thick liquids, which were later upgraded to thin liquids. When the first choking incident occurred with pulled pork described as “stringy,” a nursing assistant performed the Heimlich maneuver and the food became dislodged. The resident stated “she is fine now” and continued eating and drinking water. However, the nurse on duty did not conduct a lung assessment, did not notify the physician of this change in condition, and the resident remained on her regular diet.

Several days later, the resident developed a productive cough with yellowish sputum and occasional bright red blood, along with sore throat and ear pain. A chest X-ray revealed bilateral infiltrates in both lungs consistent with pneumonia, along with a moderate hiatal hernia. She was started on antibiotics. The very next evening, the resident choked again while eating chicken and dumplings. Tablemates alerted staff, and another nurse performed the Heimlich maneuver. The resident was able to speak afterward with a raspy voice and declined further evaluation outside the facility. Only after this second incident did the physician receive notification about any choking problems and order a pureed diet and speech therapy evaluation.

The speech therapist stated she was completely unaware of the first choking incident and only learned of the problems when the evaluation order came through after the second episode. She noted that the recent chest X-ray showing bilateral lung infiltrates suggested the resident “could have possibly aspirated.” The resident consistently described her experience as food feeling stuck in her chest area below her throat, and she stated that during these episodes she could still breathe and talk. She expressed relief when staff intervened because “it feels like food won’t go down.”

The physician later confirmed that had he been notified after the first choking incident, he would have immediately downgraded the resident’s diet and ordered a speech evaluation. He acknowledged that performing the Heimlich maneuver when it may not be true choking carries risks, including potential rib irritation and aspiration pneumonia if the resident vomits, but stated “better safe than sorry” and that “the benefits outweigh the risks.” The facility’s administrator acknowledged that the physician should have been notified after the first choking incident. The facility’s own policy required that physicians be contacted when a change in condition occurs, particularly when a resident experiences changes beyond their usual baseline or obvious acute changes in health, yet this policy was not followed.

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