IDPH has cited and fined Aspen Rehabilitation & Health Care nursing home in Silvis after a resident there choked to death on a sandwich due to a violation of the resident care plan.
The resident involved in this nursing home choking accident was a long-term resident of the nursing home. He suffered from schizophrenia, anxiety, and dementia. Some people afflicted with this set of conditions tend to eat very quickly, shoving food into their mouth and swallowing without chewing.
This is something that places the resident at risk for choking, and this had proven to be the case for this resident. Prior to being admitted to the nursing home, the resident had a choking incident which led to an admission to the hospital intensive care unit. He also had at least three other known choking incidents at the nursing home before the fatal one. This was a resident who was clearly at risk for choking.
When there are threats to the health and well-being of nursing home residents, this must be addressed in the care planning process. There are six basic steps to the care planning process: (1) an assessment of the risks to the well-being of the resident, (2) development of a written care plan consisting of a series of steps or interventions that must be taken to address those risks, (3) communication of the contents of the care plan to the staff charged with carrying it out, (4) implementation of the care plan, (5) ongoing evaluation of the effectiveness of the care plan, and (6) revision of the care plan if there are changes in the resident’s condition or if it proves to be ineffective in practice.
The nursing home recognized that that the resident was at risk for choking, and consulted with a speech therapist for recommendations to help ensure that the resident was able to eat safely. These steps included obtaining an order for a modified diet to mechanical soft and mositening bread before serving. It also included supervision of the resident while eating, cutting food into small pieces, cueing the resident to eat nore slowly and to take sips of water in between bites. These steps were all incoporated into the resident care plan.
The resident’s family was permitted to bring food in for the resident periodically, but it had to be prepared and served by the staff. On the day of the incident, the resident’s family brought in a tuna melt sandwich. The sandwich was microwaved in the kitchen but not moistened. Due to the pandemic, the residents were all eating in their individual rooms. The resident’s meal was brought to him in his room by an aide who then left the room to pass additional meals. She returned to the room about 5 minutes later to assist the resident’s roommate.
When she got to the room, she heard a gasping sound coming from the resident and realized that he was choking. She called for help and began resuscitation efforts. However, the resident’s airway was filled with food which they were not able to successfully clear. The resident’s heart beat was lost and they were not able to regain it. An emergency room physician instructed the paramedics and staff to cease resuscitation efforts and the resident was declared deceased. Cause of death per the death certificate was anoxia due to choking on food.
There were a number of failures that led to the death of this resident.
First is that the resident was not being supervised while he was eating. The nursing home properly recognized that he was at risk for choking and took reasonable steps to identify a number of steps which could be taken to mitigate that risk. The key one here was supervision of the resident while eating – and this was not done here and was a violation of the resident care plan.
Why was there a violation of the care plan?
The simple answer is that the aide who served the meal did not know that he was supposed to be supercised while eating. She did not know this because no one told her. The resident care plan is more than paperwork – it is the game plan for the delivery of routine but necessary care for the resident. If the staff charged with carrying out the care plan doesn’t know what they are supposed to be doing, the effort in coming up with the care plan is wasted. More than that it represents a breakdown in the basic system that is intended to assure the safety of residents throughout the facility. It is a major systems failure.
The second reason was that the kitchen staff failed to follows the orders for mositening of the bread. The mechanical soft diet is supposed to help residents who have swallow difficulties and the moistening of the bread is intended to reduce the choking risk associated with bread. This step which was intended to mitigate the risk of choking was also not followed.
In the end, these failures resulted in 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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