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.
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