IDPH has cited and fined Fondulac Rehabilitation & Healthcare Center nursing home in East Peoria after a resident there was fed the wrong kind of diet and left unsupervised during dinner.
One of the lesser known risks to the health and well-being of nursing home residents is the risk of choking while eating. There are a variety of reasons that a resident may be at risk for choking including advanced dementia, behavioral issues that lead the resident to cram food in their mouths, or neuromuscular issues which impair the swallowing process. Most often, these are diagnosed following an assessment by a speech therapist. They are then addressed through the care planning process and physician orders which call for supervision while eating and therapeutic diets which which are intended to reduce the risk of choking.
The resident involved was initially admitted to the nursing home with orders for a general diet. However, after a hospital visit, she was readmitted to the nursing home with transfer orders for a therapeutic diet consisting of a mechanical soft diet with nectar thick liquids. Her care plan called for assistance of one while eating due to poor safety awareness, cognitive deficits, forgetfulness, and poor mobility. The care plan did not include the therapeutic diet. Further, the her diet orders did not include the therapeutic diet, so she continued to be fed a general diet.
On the night of this fatal nursing home choking accident, the general diet being fed to residents consisted of Salisbury Steak and other items. Due to covid precautions, all of the residents were being fed in their rooms, rather than in the dining room. The aide assigned to the resident brought the tray to the room, cut up her food, fed her a bite, and then went to deliver meal trays to other residents. As the aide came back up the hallway, she saw that the resident was blue. She got a nurse, and they pulled the resident from bed and began CPR. 911 was called and paramedics took over the resuscitation efforts, but those efforts were unsuccessful and the resident was pronounced deceased.
An autopsy was performed, and the cause of death listed on the death certificate was aspiration of food.
There are at least four issues with the care that this resident received:
- Continuity of care – We have written several times about how critical it is for the well-being of residents that the transfer orders that were in place for the resident upon discharge from the hospital be carried forward into the nursing home (see here, here, here, and here for examples). Nursing homes are businesses, and well-run businesses have systems in place to make sure that the routine and necessary operations of their business are carried out. Ensuring continuity of care is one of those operations, and this was not done here as the order for the therapeutic, mechanical soft diet was not implemented. As a result, the resident was fed the Salisbury Steak that she choked on.
- Failure to implement care plan – This resident’s care plan called for assistance of one with eating. After the tray was served to her she was left unattended and unsupervised. While she was alone, she choked. The whole point of incorporating the supervision while eating was to prevent just this kind of accident.
- Understaffing of the nursing home – All of the residents in the facility were eating in their rooms as a covid precaution, and aides were forthright with the state surveyor that they simply did not have enough people on hand to supervise all of the residents who needed help eating while they were all being served with in their rooms. Federal regulations require that nursing homes have enough staff on hand to meet the care needs of the residents 24/7. As a one aide put it, “We do not have enough staff to accommodate all those people that are being quarantined in tehri rooms that need assistance while eating. We normally only have about one or two people available to watch over the residents that need supervision with eating. None of the nurses or management staff help us, and it would be nice if they did.”
- Quarantine – The policy in place at the time was that is there was a positive case in the building (which there was), then all of the residents were quarantined, regardless of covid positive status. Not only is that sort of isolation harmful to residents, but in the case of residents who require supervision, it makes it difficult to impossible to provide the necessary supervision. Had the resident involved been allowed to eat in the dining room, she likely would have been seated at a feeder table where she would be fed under the direct supervision of staff, and this fatal accident would have been avoided.
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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