IDPH has cited and fined Chicago Ridge Nursing & Rehab nursing home after a resident there choked to death on a sandwich.
One thing that families almost never envision being a possible outcome when they admit a family member to a nursing home is the possibility that their loved one could choke to death on food. However, there are residents in nursing homes who are at risk of choking and sadly for some, that possibility comes to pass with deadly results.
There are two main factors that place residents at risk for having a nursing home choking accident. The first of these is physical; the other is psychiatric or behavioral. The kinds of physical issues that place residents at risk for choking would include things like poor dentition or some form of chewing or swallow dysfunction – often associated with neuromuscular issues such as movement disorders or the residual effects of strokes. The kinds of psychiatric issues that may place a resident at risk for may include dementia or some form of behavioral disorder which results in compulsive or uncontrolled behaviors with regard to food.
When a resident is at risk for choking, this should be addressed in the care planning process. This may include having a swallow evaluation done by a speech therapist to come up with modified diet orders or other approaches to eating which can serve to reduce the risk of choking. The recommendations of the speech therapist should be incorporated into physician orders and/or the resident care plan, which then must be carried out on a day-to-day, shift-to-shift basis.
One of the kinds of records that are unique to the nursing home industry is the Minimum Data Set, or MDS. The MDS collects information regarding the resident’s condition, care needs, and the levels of assistance needed. The MDS forms part of the basis by which the reimbursement (or payment) levels for the nursing home are set, so there is a requirement that the MDS be completed under oath. Because the MDS is certifying that the resident needs and is receiving a given level of care, the care shown on the MDS is usually incorporated into the resident care plan.
The resident at issue had a number of medical issues, including suffering from dementia and having had a history of stroke. There was a physician order in place for a puree diet. The resident had a series of know n behaviors, including frequently goin into other resident’s rooms and stealing food from other residents. Her care plan included one person assistance and supervision while eating and supervision related to her dementia. The staff interviewed after this choking incident however told the state surveyor that she was able to eat without supervision and was alert and oriented to person, time, and place.
Her Minimum Date Set (MDS), however, told a different story. It described her as having severe cognitive impairments. With regard to eating, it stated that she required supervision of one while eating, that she experienced loss of food or liquid from the mouth while eating, and that she showed signs of a swallowing disorder in the form of pocketing while eating. This is very clearly the picture of a resident who was at risk for choking and required supervision. This is also consistent with the care plan.
On the day of this nursing home choking accident, the resident was found unresponsive in bed with a piece sandwich in her mouth. She was not breathing. Paramedics were called, but since she was a DNR, they did not attempt to resuscitate her and did not bring her to the hospital. Case of death per the death certificate was asphyxia due to choking on a food bolus.
There were a number of shortcomings in the care that this resident received which led to her death:
- The staff was not aware of what the care plan called for – they believed that the she was capable of eating independently when she required supervision due to her swallow difficulties and cognitive impairments. Communicating the contents of the care plan to the staff charged with carrying it out is a basic part of the delivery of care via the care planning process;
- The care plan did not address her known behavior of taking food from other residents. The physician’s order called for a puree diet and consumption of anything that was not pureed would be a violation of that order. As part of the care planning process, the care plan must be revised when it prove inadequate in practice. If the resident was taking food from other residents which placed her at risk for choking, this is a risk to the health and well-being of the resident which must be addressed in the care plan. Sadly, it was not.
- The care plan called for supervision of the resident, but we know that leading up to the choking incident, she obtained a sandwich from somewhere, began to eat it, and choked on it – all without the knowledge of the staff. As noted above, the staff should have been monitoring this resident specifically for the taking of food which she was not supposed to have, but that was not being done – and it also appears that the more general supervision was lacking as well.
Together, all of these failures led to the very preventable death of this resident. 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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