IDPH has cited and fined Spring Creek nursing home in Joliet after a resident there choked to death due to a lack of care planning.
The care planning process is the basis for for much of the routine care that is provided on a day-to-day basis in nursing homes. The process starts with an assessment which identifies the risk to the health and well-being of the resident and then puts into place interventions which need to be carried out by the staff on a day-to-day, shift-to-shift basis. The care plan must be communicated to the staff, and its effectiveness must be evaluated on an ongoing basis and changed if it proves ineffective in practice, fails to meet the care needs of the resident, or if there are changes in the resident’s condition.
Choking is something that may pose a risk to the health and well-being of nursing home residents. Residents may have difficulties with chewing or swallowing due to neurological or muscular disorders. Cognitive or behavioral issues might compound the problem by leaving the resident without real means to manage their behavior or with a lack of insight as to the risk that certain foods may pose to them. When this is the case, a well-done care plan usually includes a consultation with a speech therapist to help determine what sort of diet consistency is safe for the resident, assistance with eating which is provided at a feeder table in the dining room, and close supervision around food.
The resident at issue had a number of long term medical and cognitive issues and had been admitted to the nursing home from a group home. Among these issues were profound intellectual disabilities, a history of intracerebral hemorrhage, dysphagia (difficulty with swallowing), and Parksinson’s Disease. Around the time of his admission, the social services director spoke with the group home that the resident came from and was told that the resident engaged in pica (putting nonfood items in his mouth) and grabbing food off other resident’s plates. In short, this was a resident who was at very high risk for choking.
Given his risk profile with physical and mental/cognitive limitations that placed him at risk for choking, putting a choking prevention care plan into place was absolutely necessary. The social services director told the surveyor that she put one in place for the resident at the time admission, but that was never done. There was no referral to a speech therapist, no modified diet, no assistance or supervision with eating.
Even without the choking risk being addressed in the formal care planning process, there were other windows in which this resident’s choking risk could and should have been addressed. After the resident was admitted to the facility, nurses on the floor noted on five different occasions within the two weeks before the resident choked that the resident was taking food from other and residents and/or jamming food into his mouth.
On the day of this nursing home choking accident, the staff noticed that the resident was pushing his wheelchair through the dining room and was turning blue. The nurses swept his mouth clear of scrambled eggs and initiated CPR. 911 was called and when the paramedics arrived, they cleared additional eggs from the resident’s airway. When they attempted to intubate the resident, more eggs interfered with the placement of the tube. He was brought to the hospital where still more eggs were retrieved from the resident’s airway. The resident did not survive and was declared deceased in the emergency room.
There were a number of basic breakdowns in the care planning process that resulted in the wrongful death of this nursing home resident. First, even though the resident was clearly at risk for choking, there was no care plan put into place during the formal care planning process. After that, there were multiple episodes of behaviors which should have suggested to the nurses who were noting his behaviors of grabbing food and stuffing his mouth full that this was a resident who was at risk for choking and to see what the care plan was to address this. Discovery that this resident’s choking risk had not yet been addressed in the care plan should have led to a revision of the care plan. This is an outcome that could have been avoided by simply placing the resident at a feeder table where he could have been closely supervised during meals.
A simple breakdown in care leading to a horrific outcome – and the fact that no one took time to realize that this resident’s rather obvious risk of choking was not being properly addressed is a result of the fact that nurses in a nursing home setting often are stretched so thin by the grind of providing day-to-day care that they do not have time to give critical thought to the needs of resident’s. Sadly, that is directly related to the nursing home business model and understaffing of nursing homes. 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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