IDPH has cited and fined River Bluff nursing home in Rockford after a resident there choked to death on a peanut butter and jelly sandwich.
There are certain medical conditions which can increase the risk of a nursing home resident having a choking accident. One of these is Alzheimer’s; another is having a history of having had a stroke. With Alzheimer’s patients the advancing disease may cause the brain to no longer properly process the commands to chew and swallow, leading to an increased risk of choking. With regard to a history of stroke, the damage from the stroke may cause deficits in chewing and swallowing which lead to an increased risk of choking.
As with any risk to the health and well-being of a nursing home resident, the risk of choking is one which should be addressed in the resident care plan which then must be communicated to the staff charged with carrying out the task of supervising the resident while eating and then whatever steps are provided for must be carried out on a day-to-day, shift-to-shift basis. When the steps outlined in the care plan are not carried out, this exposes the resident to an increased and unnecessary risk of experiencing a choking accident.
The resident at issue here was at risk for choking. She suffered from Alzheimer’s and apparently had a stroke in the past as also suffered from hemiplegia (paralysis on one side of the body) and dysphagia (difficulty swallowing), both of which are common residuals from having suffered a stroke. She also had experienced a choking incident a year earlier in which she choked on a piece of a grilled cheese sandwich.
To address the choking risk, the nursing home had a care plan which included a mechanical soft diet following an assessment and recommendations from a speech therapist. There was also a physician order in place for a mechanical soft diet. A mechanical soft diet is often used to address a resident’s choking risk and consists of items which are easily swallowed with minimal chewing effort.
On the day of the accident, the resident was eating dinner in the dining room of the memory care unit with two aides at the table. She did not want the chili that was being served that night, so the aide assigned to help feed her that evening made a peanut butter and jelly sandwich for her. She prepared this, in her words, “the same way I would do for my kids” with jelly packets, creamy peanut butter, and bread. As the resident ate the sandwich, she began to show signs of choking. One of the aides brought in a nurse who performed the Heimlich maneuver which cleared small amounts of the sandwich from her airway. She was brought by paaramedics to a local emergency room where she was pronounced deceased.
So what was the problem here that led to the wrongful death of this nursing home resident? There are two major issues:
- The aide caring for her at the time of this choking accident did not know that she was on a mechanical soft diet. Assuming that things were done properly, she would have received a mechanical soft diet from the kitchen, but having the staff who was supervising this resident while she ate not know what her diet was represents a serious breakdown in the delivery of care, as it meant that neither the care plan not the doctor’s orders were being carried out.
- The sandwich that she made was not safe for this resident to eat. The tackiness of the peanut butter is something that requires more swallow effort than a resident on a mechanical soft diet should be expected to offer, so making a sandwich like you do for your kids is not an option for residents on a mechanical soft diet. There was an option for these residents to get a peanut butter and jelly sandwich, but that involved sandwiches that were premade by the kitchen in a way that blended the peanut butter and jelly to thin the peanut butter out to make it easier to swallow. These staff members did not realize that what was required to provide a peanut butter and jelly sandwich and did not know that there was a safe alternative available in the kitchen.
A series of simple failures leading to a tragic result.
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