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.
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